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Water planning programme annual survey

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Title: *

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Initials: *

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Surname: *

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House Number *

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Postcode: *

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Tel. No (daytime):

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Tel. No (evening):

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Mobile:

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Email: *

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Tenure Type: *

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Habitation: (Number of people)

Permanently living there

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Living there week day only

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Living there weekend only

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Living there term time only

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Living there term break only

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Age Profile:

(Number of people)

0 – 2 Years

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3 – 5 Years

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6 – 10 Years

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11 – 15 Years

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16 – 17 Years

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18 – 24 Years

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25 – 34 Years

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35 – 44 Years

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45 – 54 Years

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55 – 59 Years

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60 – 64 Years

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65+ Years

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Vocation:

(Number of people)

Work (Full Time)

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Work (Part Time: 8 – 29 hrs)

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Work (Part Time: Up to 8 hrs)

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Housewife/ Househusband

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Retired

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Unemployed

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Full Time Further Education

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School

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Pre - School

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Other

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Number of Facilities:

Single Flush Toilet

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Dual Flush Toilet

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Wash Basin

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Kitchen Sink

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Bath

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Bidet

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Electric Shower

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Shower direct from Combi-Boiler

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Power Shower

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Other *

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* Please specify:

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Number of Amenities:

Out Buildings

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Green House

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Ornamental Water Feature

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Outside Tap

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Fish Pond

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Garden Hose

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Sprinkler

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Paddling Pool (also provide approx dimension)

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Swimming Pool

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Other feature requiring water *

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* Please specify:

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Number of Appliances:

Automatic Washing Machine

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Twin-Tub Washing Machine

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Single–Tub Washing Machine

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Dish Washer

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Water Softener

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Waste Disposal Unit

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Does anyone in your home have any special needs that we should be aware of? (E.g. Disabled, Home Kidney Dialysis, etc)

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If yes, please specify

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Please tick the box if: *

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