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...................................._______