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Cross-Connection Control Survey: Residential

  1. State Law requires the public water system to survey their consumers not less than once every five (5) years.

    Completing & returning this Form, fulfills the State of Nebraska DHHS Regulation Title 179 requirement.

    Failure to complete and return this Report Form to the City of Columbus, may warrant a disconnection of water service by the Columbus Wastewater Collection / Utility Division that must perform an on-site inspection before restoring service.

  2. Account number can be found on bill or in address area of Cross-Connection Control Survey letter. Account Number Format: 123-12345-12

  3. Do you have any of the following at your home?

  4. Private Well*

    1. Private well that is connected to household plumbing?

  5. Private Well: Test Backflow

    If Yes, is it protected by a testable backflow preventer?

  6. Pool*

    2. Swimming pool or hot tub?

  7. Pool: Test Backflow

    If Yes, is it protected by a testable backflow preventer?

  8. Softener*

    3. Water softener?

      1. Softener: Test Backflow

        If Yes, is it protected by a testable backflow preventer?

      2. Irrigation System*

        4. Underground lawn irrigation system?

      3. Irrigation System: Test Backflow

        If Yes, is it protected by a testable backflow preventer?

      4. Threaded Faucet(s)*

        5. Outside threaded faucet(s) or yard hydrant(s)?

      5. Threaded Faucet(s): Test Backflow

        If Yes, is it protected by a testable backflow preventer?

      6. Chemical Sprayer*

        6. Chemical Sprayers connected to garden hoses?

      7. Chemical Sprayer: Test Backflow

        If Yes, is it protected by a testable backflow preventer?

      8. Boiler*

        7. Boiler heat or water to air heat pump?

      9. Boiler: Test Backflow

        If Yes, is it protected by a testable backflow preventer?

      10. Lab Facility*

        8. Photo lab, chemical, medical, or other lab facility?

      11. Lab Facility: Test Backflow

        If Yes, is it protected by a testable backflow preventer?

      12. Leave This Blank:

      13. This field is not part of the form submission.