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Whole House Water Filtration System Questionnaire

Date:
Your name:
Address:
 
City: State: ZIP:
Phone #: Fax:
E-mail:
Referred by:

# of people in the household:
# of kitchens:
# of sinks in the kitchen:
Counter top material
(ex.: granite, formica, etc.):
# of fixtures in the sink
(ex.: center faucet, sprayer, soap dispenser, etc):
Is there an instant hot/cold dispenser on the sink? Yes No
Do you have a garbage disposal unit? Yes No
 
# of bathrooms:
# of shower stalls in use at the same time:
 
Size of the main water pipe:
 
What is your water source: Municipal Well
If you are using well water, please answer the following:
How deep is the well? ft.
What is the pump pressure?
Is the well chlorinated? Yes No
Has your well been tested?
If yes, please fax any test results to (718) 369-2866
Yes No
 
Do you have red or brown stains (rust)
on any sinks or fixtures?
Yes No
Do you have any white scale material
on fixtures or pots?
Yes No
Are there any parasites in your water? Yes No Don't know
Are there any objectionable odors or tastes
in your water (such as roten egg smell)?
Yes No
 
Do you have a basement? Yes No
If yes, please answer the following questions:
Is the main pipe accessible from the basement? Yes No
What is the approximate height of the ceiling? ft.
 
Do you have a sprinkler system? Yes No
If yes, please answer the following questions:
Do you have a check valve or a back flow valve?
Is the main pipe accessible
after it leaves the check valve?
Yes No
 
Additional notes:
 


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