1

Contact Information (Optional)

Contact Information (Optional)

Name

Email

2

I am responding to this form on behalf of

 *

I am responding to this form on behalf of

Myself

Agency/Organization (Please specify your organization below) If other, type text here.

3

What option below best indicates your primary use of water?

 *

What option below best indicates your primary use of water?

Domestic

Municipal/Public

Industrial

Agricultural

Small Community

Other (Please describe below) If other, type text here.

4

What is your main source of water supply?

 *

What is your main source of water supply?

Domestic Well(s) - If domestic well(s), zip code: If other, type text here.	Connection to Water Supplier - If connection, name of water supplier: If other, type text here.
Diversion of Surface Water - If diversion, Zip Code: If other, type text here.	Other - Please describe If other, type text here.

5

Which County-wide or local actions were you or your agency/organization aware of or directly engaged in during the last drought? (Select all that apply.)

Which County-wide or local actions were you or your agency/organization aware of or directly engaged in during the last drought? (Select all that apply.)

Water Hauling/Emergency Water Supply	Mandatory Reductions in Outdoor Water Use
Curtailment of Surface Water Rights	Consolidation of Water Suppliers
Conservation Programs (e.g., rebates, water loss audits)	Other(s) - Please describe below If other, type text here.

6

Did you experience any of the following impacts during previous droughts? (Select all that apply.)

Did you experience any of the following impacts during previous droughts? (Select all that apply.)

Water Supply Curtailments	Municipal Conservation Measures	Dewatered Well(s)
Higher Water Bills	Lower Pumping Rates	Increased Pumping Costs
Decline in Agricultural Production	Impacts to Water Quality	Other(s) - Please describe below If other, type text here.

7

How familiar are you with SB 552 and drought conditions in your region?

 *

How familiar are you with SB 552 and drought conditions in your region?

1 (Not at all familiar)

2

3 (Somewhat familiar)

4

5 (Very familiar)

8

Is there anything else you would like the County to know or consider regarding drought and water shortage planning?

Is there anything else you would like the County to know or consider regarding drought and water shortage planning?

9

Would you like to receive email updates on activities of the Mendocino County Drought Task Force, including reminders about public stakeholder meetings?

Would you like to receive email updates on activities of the Mendocino County Drought Task Force, including reminders about public stakeholder meetings?

Yes - Email (if different than above): If other, type text here.

No

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

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