Private Water Supply Questionaire 2010

Please take time to complete this questionnaire. It will provide vital information that will help prioritise Risk Assessments

Private Water Regulations 2009

Private Water Supply Questionnaire 2010

1.	Name

2.	Address of property

3.	Post code

4.	Daytime number

5.	Email address

Owner or tenant (please indicate)

Owner

Tenant

7.	Landlord's name & address (if applicable)

Is the property served by a private supply mains water or both (please tick as appropriate)

Private supply

Mains

Both

9.	If mains only, please finish, sign & return?

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10.

If on a private supply please indicate the type of supply (if using more than one type, please quote the number of each supply type)

Surface waters type (eg river, lakes, streams & reservoir)

Spring

Well

Borehole

11.	Other please specify

12.

Is the private water supply shared with any other property?

Yes

13.	If yes, please list all properties concerned to the best of your knowledge

14.

Does the private water supply originate on your own land?

Yes

15.	If known, please indicate the name and address of the land owner on whose land the supply originates

16.	Please give an estimate of the average daily volume of water supplied, in litres or M3, if known

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Purpose(s) for which the premises are used (Please tick as appropriate)

17.

Domestic Residence

Number of people living in the property at maximum occupancy

18.

Hotel/Guest House

Number of people living in property at maximum occupancy

Number of guests accommodate in property at maximum occupancy

19.

Commercial/Industrial Premises

Number of people normally working on the premises

20.	Food or drink production for sale (Please specify type)

21.

Restaurant/Cafe

Approximate average number of people using the restaurant or cafe on any day during previous calendar year

22.

School/College/University

Number of students

Number of staff

23.

Residential Care Home/Hospital

Number of residence/patients

24.

Holiday accommodation (eg holiday let, campsite, caravan site, holiday village)

Average number of people accommodate on the premises

Other

25.	Please specify

26.	Period for which the premises is used (please state number of months during last year that premises were used)

27.

Purpose for which the private water supply is used on your premises (please tick as appropriate)

Domestic use (drinking, washing,cooking)

Food & drink production for sale

Dairy farming

Washing produce

28.	If other please specify

29.	If two or more supplies are used for different purposes, please explain below

30.

To the best of your knowledge do you have any intermediate water storage tanks/chambers?

Yes

31.	If yes please provide details, including numbers?

32.

Does the private supply have any treatment fitted?

Yes

33.	A) At source (Provide details)

34.	B) At intermediate water storage tanks/chambers (Provide details)

35.	C) At property (ie end of tap) (Provide details)

36.

Do you have a Contingency Plan to deal with problems with the quality/quantity of the supply?

Yes

37.	If yes, please provide details

38.

Do you pay a charge (other than abstraction charge) for the supply of water to your premises

Yes

39.	If yes, please provide details of who you pay the charge to, amount etc

40.

Single dwellings on a private supply fall below thresholds for requiring a risk assessment should this apply to you, do you wish for a risk assessment to be carried out? (Please note there will be a charge for this)

Yes

41.	Any additional information concerning your supply?

Please take time to complete this questionnaire. It will provide vital information that will help prioritise Risk Assessments

Private Water Regulations 2009

Private Water Supply Questionnaire 2010

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Purpose(s) for which the premises are used (Please tick as appropriate)

Disclaimer: Please note names & addresses will not be published to the public domain, they are only being used for the purpose of this questionnaire

Thank you for taking the time to complete this questionnaire