Johnson County Wastewater
Sewer Backup Response Questionnaire
Please fill out the information below and press the submit button at the end. You will be notified when your questionnaire is processed. Thank you.

1. Property Owner Information:

First Name : *

Last Name : *

Street Address : *

City : *   State : *   Zip Code : *

E-mail Address :

Home/Cell/Preferred Phone Number with Area Code : *

Work Phone Number with Area Code :

* Above Information Required

2. How long have you lived at this address? : years months

3. What is the approximate age of the house? : years months

4. What was the most recent date you experienced a sanitary sewer backup? :

Drop Down Calendar

5. Have you experienced water in your basement from surface water flooding? :

6. If the answer to question five was yes, please indicate the source :

7. What was the extent of the most recent sewer backup? :


8. What was the extent of the most severe sewer backup? :


What was the date of the most severe sewer backup:
Drop Down Calendar

9. Please indicate the source of the most severe sewer backup :

10. Is your home equipped with either of the following devices? :

11. Have any modifications been completed on your property to remedy the sanitary sewer backup problem? :

If yes, please decribe and indicate when completed and by whom:

12. Have any of your neighbors experienced a sewer backup during a rain event?

If yes, please provide their names and addresses:

13. Please provide any additional information you deem relevant:

14. Have you contacted the Federal Emergency Manamement Agency (FEMA) or any other agency to inquire about flood damage assistance or mitigation?

If yes, please provide the Case Number: