Residential Cross Connection Control Survey

In order to protect the water supply from being contaminated, we are conducting a survey to determine if there are any hazardous conditions that could affect our drinking water. We appreciate you taking the time to complete this survey. If you have any questions regarding this survey please contact your local municipality or village clerk.

Your City, Village, or Community *

Last Name *

First Name *

Date *

Address *

Phone *

1a) Do you have any other sources of water, such as a private well or a tank that is connected to the water system? *

Yes

1b) Mark all that apply:

Well

Pond

Lake

Tank

Other

2) Do you have a permanent in-ground lawn irrigation system installed on your property? *

Yes

3a) Do you have a swimming pool? *

Yes

3b) Is the pool filled by a permanent connection to the water supply?

Yes

4) Is your building heated by a boiler? *

Yes

5a) Are there any backflow prevention devices installed on the premises? *

Yes

5b) Has the device been tested?

Yes

6) What type of water service line do you have coming into your home? (Service line before the water meter) *

Galvanized

Copper

Plastic

Lead

I don't know

7) What type of water lines do you have running throughout your home? Mark all that apply: *

Galvanized

Copper

Plastic

Lead

8a) Do you have a sump pump? *

Yes

8b) Is it connected to the sewer system?

Yes

9) Do you have down spouts from the gutters connected to the sewer system? *

Yes

Next steps after survey completion

The water system is required by the EPA to have a Cross Connection Control Program in place. Part of the program is a mandatory Bi-Annual Cross Connection Control Survey. This survey must be filled out by all residents and businesses connected to the water system.

If you do have a backflow prevention device installed it has to be tested/inspected annually by a plumber with a backflow prevention certification.

Email (will be used to send you a confirmation)