PUBLIC DRAINAGE SURVEY

Please complete a separate form for each problem area. Provide as much information as possible.

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* 1. What type of problem have you observed? (check all that apply)

Flooding

Potholes

Damaged gutters/drains/manholes

Other (please specify)

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* 2. Where is the problem located? Please provide an address or road intersection.

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* 3. Approximately how long has the problem existed?

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* 4. Has the problem gotten any worse over time?

Yes

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* 5. The extent of flooding depends on the amount of rain that occurs. Please answer to the best of yourability the following questions concerning the amount of flooding:

Does it take a large storm to flood the area?

On average, how often does the area flood?

On average, how deep is the flooding?

On average, how long does it take for the floodwaters to go away?

What is the worst flood you have seen in this area?

Approximately when did the worst flood occur?

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* 6. Is there any trash left behind when the floodwaters are gone?

Yes

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* 7. In your opinion, what may be causing the problem? (check all that apply)

Water has nowhere to go

Pipes are too small

Inlets/pipes are clogged or damaged

King tides

Other (please specify)

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* 8. Additional Comments:

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* 9. Attach a Photo if Available

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* 10. Attach a Photo if Available

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* 11. Attach a Photo if Available

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* 12. May we contact you if we have any questions? (Contact information will be kept confidential)

Yes

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* 13. Contact Information:

Neighborhood Association:

Name:

Street Address:

City:

State:

Zip:

Phone:

Email: