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*Safe, Clean Water and Natural Flood Protection Program
Priority A: Ensure a Safe, Reliable Water Supply
Priority B: Reduce Toxins, Hazards and Contaminants in our Waterways
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Priority D: Restore Wildlife Habitat and Provide Open Space
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Guadalupe River - Tasman Dr to I880
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Sunnyvale East and West Channels Flood Protection*
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John L. Varela, District 1
Barbara Keegan, District 2
Richard Santos, District 3
Linda J. LeZotte, District 4
Nai Hsueh, District 5
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Gary Kremen, District 7
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DIY Water Wise Indoor Survey Worksheet
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DIY Water Wise Indoor Survey Worksheet
Name
Address
City
Zip Code
Email
Telephone
Date of Survey
Meter reading
Provide the number shown on the dial or meter’s face.
The Pin Test
Does your water meter register when all your water using fixtures and appliances are turned off?
Yes (Go to House Line Test)
No (Go to Toilet Test)
The House Line Test
The House Line Test: Does the irrigation system branch off the house line before the house line shut-off valve?
Yes
No
Does the irrigation system branch off the house line before the house line shut-off valve?
Does the irrigation system have a shut-off valve?
Yes
No
After you turn off the house line and do a second Pin Test: Is there movement?
Yes (Call a
plumber
to fix a house line leak, or check irrigation system)
No (Leak is beyond this valve. Go to Toilet Test)
Turn on the house line valve using the same number of turns you to turn it off.
Leaks
Did you find any leaks indoors?
Yes
No
Any signs of standing water damage?
Yes
No
Any signs of leakage or water damage?
Yes
No
If so, where?
The Toilet Leak Test
Listen: Did you hear a noise?
Questions
Yes
No
Toilet 1
Yes
No
Toilet 2
Yes
No
Toilet 3
Yes
No
Look: Did your parts work smoothly?
Questions
Yes
No
Toilet 1
Yes
No
Toilet 2
Yes
No
Toilet 3
Yes
No
Look: Does water stop one inch below the top of the overflow pipe?
Questions
Yes
No
Toilet 1
Yes
No
Toilet 2
Yes
No
Toilet 3
Yes
No
Dye Test: Did the flapper leak?
Questions
Yes
No
Toilet 1
Yes
No
Toilet 2
Yes
No
Toilet 3
Yes
No
Measure Flow Rate
Status message
Showers
Showers: Do your showerheads use more than 2.0 gpm?
Yes
No
Total Showerheads
Shower Flow Rate A
Enter the highest flow rate
Shower Flow Rate B
Enter the next-highest flow rate
Status message
Bathroom Sink Faucets
Do your bathroom sink faucets use more than 1 gallon per minute (gpm)?
Yes
No
If you found you have different flow rates throughout your home, enter the highest flow rates in ‘A’, then the next highest flow rate in ‘B’. If you have more than two flow rates,
please provide any additional details in the ‘Comments’ at the end of this form.
Total Bathroom Sink Faucets
Bathroom Sink Faucets Flow Rate A
Enter the highest flow rate
Bathroom Sink Faucets Flow Rate B
Enter the next-highest flow rate
Status message
Kitchen Sink Faucets
Do your kitchen sink faucets use more than 1.5 gallon per minute (gpm)?
Yes
No
Total Kitchen Sink Faucets
Kitchen Sink Faucets Flow Rate A
Enter the highest flow rate
Kitchen Sink Faucets Flow Rate B
Enter the next-highest flow rate
Free Devices Requested
Notes:
Please note we will send you efficient faucet aerators, showerheads or toilet flappers based on your responses above, which may be less than what you specify below.
Toilet Flappers Requested
Showerheads Requested
For a 2.0 gpm showerheads, enter the quantity you want. Otherwise, check your local hardware store for even more efficient
WaterSense-labeled showerheads
.
Bathroom Sink Aerators Requested
Kitchen Sink Aerators Requested
Appliances
Is there any sign of water damage around your appliances?
Yes
No
Comments
Comments