If marked yes, please complete and submit a DuPage County Health Department Public Water Connection Information Sheet.
If well has been sealed or capped, please attach a copy of all pertinent documentation to support this work.
If domestic is the only item checked, please sign below.
I hereby certify that all information above is accurate and that all connections to the potable water supply system are for domestic use only and will be protected from backflow and cross connection hazards.
If other than domestic is checked above, please proceed to next section.
If other than domestic is checked in previous section, a licensed plumber also licensed in backflow prevention and cross connection control must conduct a site inspection and complete this section.
I hereby certify that all items related to backflow and to cross connection control have been inspected, tested, or replaced and are in satisfactory condition.