END

WATER SUPPLY

TYPE

WELL

CISTERN

COMMUNITY

MUNICIPAL

RECOVERY

LOW

ADEQUATE

UNKNOWN

WATER PUMP

TYPE

JET

POWER

PRESSURETANK

CAPTIVE AIR

GALVANIZED

WATERLOGGED

NO

YES

PRESSURELOW________________PSI

HIGH________________PSI

SUPPLY PIPING

¾”

1"

1 ¼”

OTHER________

WELL LINE

COPPER

PVC

GALVANIZED

CPVCShut – Off

Valve

YES

NO

ADDITIONALPIPING

ADDITIONAL COSTESTIMATED AT

SILCOCKSHOW MANY?

$

YES

NO

BYPASSING

COPPER

CPVC

PVC

PEX

OTHERSHUT-OFF

VALVE

YES

NO

INSTALLAREA

BASEMENT

WELL PIT

1" FLOOR UTILITY ROOM

CRAWL SPACE

GARAGE

HEATED

UNHEATED

OPEN

CRAMPED

LIGHTED

POOR LIGHT

NO LIGHT

DRAINAGE

NONE

FLOOR DRAIN

SUMP PUMP

_____________

DISTANCE

FEET

DUPLEX

LIGHT

PANEL

YES

NO

ELECTRICPOWER

NO

GRAVITYOVERFLOW?

YESCUSTOMER AWARE

YES NO

DISTANCE

____________ FEET

PLUMBING ASSESSMENTCUSTOMER NAME ______________________ INSTALL DATE ______________________