Form Center

By signing in or creating an account, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.

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. Can be found on your City of Columbus Utility Bill in the Billing Information section.

  3. Account number can be found on your City of Columbus Utility Bill.
    Account Number Format: 123-12345-12

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

  5. Private Well*

    1. Private well that is connected to household plumbing?

  6. Private Well: Test Backflow

    If Yes, is it protected by an Approved Backflow Prevention Assembly?

  7. Pool*

    2. Swimming pool or hot tub that is connected to household plumbing?

  8. Pool: Test Backflow

    If Yes, is it protected by an Approved Backflow Prevention Assembly?

  9. Softener*

    3. Water softener?

  10. Softener: Test Backflow

    If Yes, is it protected by an air gap at the discharge hose?

  11. Irrigation System*

    4. Underground lawn irrigation system?

  12. Irrigation System: Test Backflow

    If Yes, is it protected by an Approved Backflow Prevention Assembly?

  13. Threaded Faucet(s)*

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

  14. Threaded Faucet(s): Test Backflow

    If Yes, is it protected by an Approved Backflow Prevention Assembly or Hose Bib Vacuum Breaker?

  15. Chemical Sprayer*

    6. Chemical Sprayers connected to garden hoses?

  16. Chemical Sprayer: Test Backflow

    If Yes, is it protected by an Approved Backflow Prevention Assembly?

  17. Boiler*

    7. Boiler heat or water to air heat pump?

  18. Boiler: Test Backflow

    If Yes, is it protected by an Approved Backflow Prevention Assembly?

  19. Lab Facility*

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

  20. Lab Facility: Test Backflow

    If Yes, is it protected by an Approved Backflow Prevention Assembly?

  21. Leave This Blank:

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