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First name
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Last name
Email
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Phone
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Postal Code
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Does your property use a private well and septic system?
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Yes, both
Only Well
Only Septic
Not Sure
When was your last septic pump-out?
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Within 1 year
1-3 years ago
3+ years ago
I don't know
When was your last well water test?
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Within 1 year
1-3 years ago
3+ years ago
I don't know
What concerns you most about your well or septic system?
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