Residential Cross Connection Survey

  • Date Selection

  • Please check a mark in the box that best fits your answer per question.

    Yes:  A potential cross connection exists at this property.

    No: This type of cross connection does not exist at this property.

    Don't Know: Water pipes may be concealed.

  • Underground Lawn Irrigation System?
  • Swimming Pool or Hot Tub?
  • Photo lab, chemical, medical, or other lab facilities?
  • Private well or second water service line?
  • Lawn or garden chemical sprayer attached to hose?
  • Water softener?
  • Boiler/Hot water heat?

  • If you need help completing the survey call Guy Smale, Plumbing Inspector, 815-363-2170.