Cross-Connection Survey

What is a cross-connection?
A cross-connection is any actual or potential physical connection between a public water system (or the
customer's water system) and any source of non-potable liquid, solid, or gas that could contaminate the
potable water supply by backflow.

GALLATIN PUBLIC UTILITIES
Residential Cross-Connection Control Survey

What is a cross-connection?

A cross-connection is any actual or potential physical connection between a public water system (or the

customer's water system) and any source of non-potable liquid, solid, or gas that could contaminate the

potable water supply by backflow.

Property Address:

Occupant Name:

Occupancy:
Own Rent

This meter serves:

Home(s) How many (rental/apt.)

Building(s)
How many

Do you have? (Please select all that apply)

Swimming Pool Hot Tub Jacuzzi Solar System Green House

Underground Sprinkler System Drip/Soaker Irrigation System

Fire Sprinkler System Dark Room Equipment Portable Dialysis Machine

Insecticide Sprayers (that attach to a garden hose)

Do you have a water softener or any other water treatment system? Yes No

Do you have an auxiliary source of water, such as a well, at this address? Yes No

Do you have livestock and use a water trough? Yes No

Is your home elevated above your water meter? Yes No

Does a creek, stream, spring, or river run on or through this property? Yes No

>If yes, do you pump or draw water from this source? Yes No

Do you have a booster pump, well pump, or any other type of water pump? Yes No

Do you receive irrigation water from a different source? Yes No

Do you have a backflow prevention device on this property now? Yes No

Do you have any situation that you are aware of that could create a cross-connection? Yes No

Do you have any other water using equipment on your property not mentioned above? Yes No

If yes, please explain below: