The following information is needed to determine if certain chemicals can be applied into Lake Chemung to control nuisance weeds.

  1. Date:

  2. Name:
     

  3. Address:

    Street Address
    Address (cont.)
    City
    State/
    Zip/Postal Code
     

  4. How can we contact you?

    Home Phone
    E-mail
     

  5. Is your home connected to city water?  Yes No

  6. Do you use a well for your household water supply?  Yes No

  7. If you use a well, do you know the depth of your well?  Yes No

  8. If you know the depth of your well, how deep is it?
     

  9. What is the distance between your well and the lake shoreline (feet)?

Lake Chemung Riparian Association
All rights reserved.
Revised: 04/06/10