Cross-Connection Survey

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Cross-Connection Survey

Do you have an auxiliary water supply on your premises *

Yes

Is your home or building elevated above your water meter? *

Yes

If yes, please list below:

So you receive irrigation water from a different source? *

Yes

Do you have a water softener or any extra water treatment system? *

Yes

Do you have livestock and use a water trough or water system connected to by public water? *

Yes

Occupant Address: *

Do you have a backflow protection device on your property now? *

Yes

Do you have? (Please check all that apply) *

Hot Tub

Swimming Pool

Jacuzzi

Waterbed

Solar System

Green House

Underground Sprinkler System

Darkroom Equipment

Drip/Soaker/Irrigation System

Portable Dialysis Machine

Insecticide Sprayers (that attach to garden hose also)

Utility sink w/threaded faucet

Wood burning hot water heater

Ghost pipes (unidentified)

Do you have a booster pump, well pump, or any other type water pump? *

Yes

Thank you for completing the Cross-Connection Survey!

Phone *

Do you have any other water-using equipment on your property not mentioned above? *

Yes

Occupant Name: *

Do you have bathtub that fills from the bottom *

Yes

Do you have any situation that you aware of that could create a cross-connection? *

Yes

Date and time *

Meter Serves: Buildings How Many? *

Does a creek, river, or spring water run near or on your property? *

Yes

Meter Serves: Homes How Many? *

Signature: *

Water System

Cross-Connection Survey

Residential

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