Water Usage Survey

City of West Chicago Engineering / Building Department / Water Utility Division Water Usage Survey
Date:

MonthDayYear
Date
Building Owner:
Please indicate if a/n:

New BuildingExisting Building
Building Tenant & Business Name:
Address of Business:
Contact Name:

First NameLast Name
Phone:
123-456-7891
Is there a private well located on this property?

YesNo
If marked yes, please complete and submit a DuPage County Health Department Public Water Connection Information Sheet.
Is the well currently in use?

YesNo
If marked no, has well been properly sealed or capped?

YesNo
If well has been sealed or capped, please attach a copy of all pertinent documentation to support this work.
Potable Water Used for: (Please check all that apply)

Domestic UseMetal PlatingRadioactive MaterialsCar WashingFood ProcessingHeating/Cooling SystemsIrrigation SystemsLaundry or Dry CleaningPetroleum Processing/StorageMixing Pesticide, Herbicide or FertilizerFood PreparationPhoto LaboratoryBeverage ProcessingMixing ChemicalsLaboratory/AnalysisMachine CoolingHealth CareFire ProtectionMortuary UseOther
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.
Signature

Clear
Date

MonthDayYear
Date
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.
Plumbing Site Inspection Checklist

Vacuum Breakers, Anti-SiphonVacuum Breakers, Hose ConnectionDouble Check Valve AssemblyDual Check ValveVacuum Breakers, Pressure TypeDouble Check Valve with Atmospheric VentReduce Pressure Zone DeviceFixed Air GapAnti-Siphon Self-Draining Frost Proof Sillcocks
Comments:
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.
Signature of Cross Connection Inspector

Clear
Date

MonthDayYear
Date
Company Name
Plumbing License No.
Should be Empty:

City of West Chicago Engineering / Building Department / Water Utility Division Water Usage Survey