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2. Name
3. Email Address
5. Address
7. City
8. State
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9. Zip Code
11. Phone Number
12. Fax Number
14. How long have you owned or lived at this location?
15. Are there any soil erosion problems from a storm drainage system (i.e. pipes, drains, streams or ditches) on your property or in your neighborhood?

    1. Yes

    1. No
17. If there are soil erosion problems, please indicate location and severity of problem.
    Location
19. Severity of Problem

    1. Minor
    2. Moderate
    3. Severe
21. If there are soil erosion problems, please indicate location and severity of problem.
    Location
23. Severity of Problem

    1. Minor
    2. Moderate
    3. Severe
25. If there are soil erosion problems, please indicate location and severity of problem.
    Location
27. Severity of Problem

    1. Minor
    2. Moderate
    3. Severe
29. Have you ever experienced flooding on your property during a (non-hurricane) storm?

    1. Yes

    1. No
31. If yes, check all situations that apply and note the frequency by choosing the appropriate option:
33. Water in Storage Building

    1. Never experienced
    2. Less than once per year
    3. Once per year

    1. 2-3 times per year
    2. 3+ times per year
    3. Every time it rains
35. Water on Air Conditioning Units

    1. Never experienced
    2. Less than once per year
    3. Once per year

    1. 2-3 times per year
    2. 3+ times per year
    3. Every time it rains
37. Water in Crawl Space

    1. Never experienced
    2. Less than once per year
    3. Once per year

    1. 2-3 times per year
    2. 3+ times per year
    3. Every time it rains
39. Water Up To, Or in the Living Space

    1. Never experienced
    2. Less than once per year
    3. Once per year

    1. 2-3 times per year
    2. 3+ times per year
    3. Every time it rains
41. Yard Flooding from Stream/Ditch

    1. Never experienced
    2. Less than once per year
    3. Once per year

    1. 2-3 times per year
    2. 3+ times per year
    3. Every time it rains
43. Yard Flooding from Street Runoff

    1. Never experienced
    2. Less than once per year
    3. Once per year

    1. 2-3 times per year
    2. 3+ times per year
    3. Every time it rains
45. Yard Flooding from Adjacent Property

    1. Never experienced
    2. Less than once per year
    3. Once per year

    1. 2-3 times per year
    2. 3+ times per year
    3. Every time it rains
47. If flooding occurred, please list the approximate date(s), location and indicate depth of flooding:
49. Date
51. Location
53. Depth of Water
55. Date
57. Location
59. Depth of Water
61. Have you ever noticed flooded streets in your neighborhood?

    1. Yes

    1. No
63. If you noticed flooded streets, please provide the approximate date(s), location and depth of flooding:
65. Date
67. Location
69. Depth of Flooding
71. Date
73. Location
75. Depth of Flooding
77. Are there any other problems with the storm drainage system (i.e. pipes, drains, streams or ditches) on your property or in your neighborhood?

    1. Yes

    1. No
79. If yes, check all situations that apply:

    1. Damaged Pipes
    2. Sink Holes
    3. Pipe Blockage

    1. Stream or Ditch Blockage
    2. Drains in Need of Repair
    3. Other
81. Do you have any photographs, videotape or other records of flooding problems that occurred on your property or in your neighborhood?

    1. No
    2. Written
    3. Photos

    1. Video
    2. Other
83. Has flooding increased on your property due to the development of lots adjacent to, or near, your property?

    1. Yes

    1. No
85. Other comments including water quality concerns:
Leave This Blank:


87. 1. Receive an email copy of this form.
88. Email address

    This field is not part of the form submission.

89. Submit

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