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Cross Connection Survey 2022
All water suppliers are required by law to conduct a cross-connection control survey at least every two years. The last survey by Clark-Edgar Rural Water District was in 2020. Therefore, it is imperative that all customers again complete and return to us the following information.
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Email
*
Your email
Account Number
*
Your answer
Name
*
Your answer
Address
*
Your answer
City
*
Your answer
State
*
Your answer
Do you own or rent the property?
I own this property
I rent this property.
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Phone Number
*
Your answer
Service Address if different from above.
Your answer
Are you Connected to the service?
*
Yes
No
What is the water used for?
Residence
Farm Operation
Commercial
Industrial
Other:
Clear selection
Number of persons in household?
Your answer
Size of service line (this is not our line, it's the line from your meter to your home or business)?
Your answer
Type of plumbing in home or business?
Copper
PVC/PEX
Galvanized
Combination
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Are all connections from your previous source of water completely separated from the lines supplying water from the Water District?
Yes
No
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If you have cattle watering or any other types of fountain facilities on your property, does a proper air gap exist? A safe air gap means the minimum distance of a water inlet or opening above the maximum water level or overflow rim in a fixture, device, or container to which public water is furnished shall be at least two (2) times the inside diameter of the water inlet pipe, but shall not be less than one inch and need not be more than 12 inches.
Yes
No
I have no such devices
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Do you have a lawn sprinkling system installed?
Yes
No
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If yes, are proper backflow prevention devices installed? Please list any devices attached to your system other than normal household plumbing, such as outside hydrants, cattle watering facilities, fountains, or other appurtenances.
Your answer
Do you have a swimming pool?
Yes
No
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If yes, approximate number of gallons it holds?
Your answer
Are all outside hydrants AWWA approved (no drain back type hydrants)? If drain back hydrants are installed, do they have the proper backflow prevention devices installed?
Yes
No
I have no yard hydrants
Clear selection
Does your water meter serve more than one residence?
Yes
No
Clear selection
If commercial or industrial property, does your water meter have a RPZ (reduced pressure zone) backflow prevention device?
Yes
No
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If yes and you do have a RPZ (reduced pressure zone) backflow prevention device? When was it installed and last inspected?
Your answer
Form filled out by:
Your answer
Date Filled Out
MM
/
DD
/
YYYY
A copy of your responses will be emailed to the address you provided.
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