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Residential Cross Connection Survey

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Do not complete this survey if your letter instructs you to complete a Commercial Cross Connection Survey.

Do not complete this survey if your letter indicates that you need to TEST your Backflow Device.

State law requires consumers of public water supplies to inspect their residences and to report that inspection to the public water system every five years. Completing  and returning this form fulfills that requirement and will help prevent accidental contamination of our drinking water system.

Please correct the fields below:

Basic Information
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Basic Information
For all Yes answers, specify whether the device is protected with a backflow preventer.
Do you have a well on your property?
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Do you have a well on your property?
Do you heat your home with a hot water or steam boiler? (not a water heater)
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Do you heat your home with a hot water or steam boiler? (not a water heater)
Do you have a photographic lab or facilities using chemicals?
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Do you have a photographic lab or facilities using chemicals?
Do you have pumps which are hooked directly to the plumbing? (decorative fountain, etc.)
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Do you have pumps which are hooked directly to the plumbing? (decorative fountain, etc.)
Do you have automatic livestock waterers or tank fillers?
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Do you have automatic livestock waterers or tank fillers?
Do you have an underground lawn sprinkler system?
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Do you have an underground lawn sprinkler system?
If you have an underground lawn sprinkler system, does the system feed chemicals?
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If you have an underground lawn sprinkler system, does the system feed chemicals?
Do you have a swimming pool or hot tub?
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Do you have a swimming pool or hot tub?
Do you have a water softener?
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Do you have a water softener?
Do you have a a home water treatment system (reverse osmosis/water purifier)?
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Do you have a a home water treatment system (reverse osmosis/water purifier)?
To my knowledge, these questions are accurate.
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To my knowledge, these questions are accurate.
  1. To receive a copy of your submission, please fill out your email address below and submit.

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