BACKFLOW/CROSS-CONNECTION SURVEY REPORT FORM
Name: _______________________________________ Date: ___________________
Mailing Address: __________________________________________________________
Street Address: ___________________________________________________________
Home Phone: ____________________ Work Phone: ____________________
Are you renting this home, or do you own this property: _________
If renting, please provide the name and address of owner:
_______________________________________________________________________
Does this water meter serve more than one household? If yes, how many ___
Do you have any of the following? (Please answer Yes, No, or Don't Know)
Hot tub, Jacuzzi, waterbed and/or swimming pool___________________________________
Underground sprinkler or drip irrigation system._____________________________________
Fire sprinkler system_________________________________________________________
Solar heating system or Swamp cooler___________________________________________
Utility sink(s) with threaded faucet______________________________________________
Greenhouse________________________________________________________________
Elevation of your home 30’ above your water meter_________________________________
Boiler_____________________________________________________________________
Ornamental water system (fountains, pools, waterfalls etc.)____________________________
Livestock and use a water trough._______________________________________________
Water softener/other treatment system connected to your drinking water supply____________
Booster pump or well pump____________________________________________________
Pump or draw water from a creek, river or stream___________________________________
Portable dialysis machine in use on these premises___________________________________
Do you have a testable backflow preventer on the property now_________________________
