State Small Water System Drought Response Facilitation Reporting Form

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This form is intended to help the County gather information about challenges faced by State Small Water Systems due to ongoing drought conditions. The County's role is to facilitate communication and coordination with appropriate agencies or resources that may provide support. Please note that the County is not a water supplier and does not provide water or mitigation services unless explicitly funded and supported through Federal, State, or Local programs.

“State small water system” is defined as a system for the provision of piped water to the public for human consumption that serves at least five, but not more than 14, service connections and does not regularly serve drinking water to more than an average of 25 individuals daily for more than 60 days out of the year.

Please correct the fields below:

Please correct the field(s) marked in red below:

SECTION 1: SYSTEM INFORMATION

1

Water System Name:

*

Water System Name:

2

Water System ID (if available):

3

Contact Person:

*

Contact Person:

Full Name:

Title/Position:

Phone Number:

Email Address:

4

Preferred Contact Method

*

Preferred Contact Method

Phone

Email

5

System Location:

*

System Location:

Address/Nearest Cross Streets/Other location description:

City/Town:

Zip Code:

6

Type of Water Source: (Check all that apply)

*

Type of Water Source: (Check all that apply)

Groundwater Well(s)

Surface Water Diversion

Spring

Other: If other, type text here.

7

Population Served by the System:

8

Number of Connections/Households Served:

*

Number of Connections/Households Served:

Please proceed to the next page.

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