Water System Cross-Connection Survey

WATER SYSTEM CROSS-CONNECTION SURVEY RESIDENTIAL
Occupant Name
Occupant Address
Meter Serves how many Homes?
Meter Serves how many Buildings?
1. Do you have? (please Check all that apply)

Hot TubSwimming PoolJacuzziWaterbedSolar SystemGreenhouseUnderground Sprinkler SystemDarkroom EquipmentDrip/Soaker/Irrigation SystemPortable Dialysis MachineInsecticide Sprayers (that attach to garden hose also)Utility sink w/threaded faucetWood burning Hot Water HeaterGhost pipes (unidentified)
2. Do you have bathtub that fills from the bottom?

YesNo
3. Do you have a water softener or any extra water treatment system?

YesNo
4. Do you have an auxiliary water supply on your premises?

YesNo
5. Do you have livestock and use a water trough or water system connected to by public water?

YesNo
6. Is your home or building elevated above your water meter?

YesNo
7. Does a creek, river or spring water run near or on your property?

YesNo
8. Do you have a booster pump, well pump, or any other type water pump?

YesNo
9. Do you receive irrigation water from a different source?

YesNo
10. Do you have a backflow protection device on your property now?

YesNo
11. Do you have any situation that you are aware of that could create a cross-connection?

YesNo
12. Do you have any other water-using equipment on your property not mentioned above?

YesNo
If yes, please list below:
Print Name
Phone # (include area code)
Signature

Clear
Date

MonthDayYear
Date
Please notify this office if any of the above conditions change

NOTE: PLEASE RESPOND TO THE WATER SYSTEM CROSS-CONNECTION SURVEY AS SOON AS POSSIBLE. THIS IS A STATE REQUIREMENT OF TDEC (TENNESSEE DEPARTMENT OF ENVIRONMENT AND CONSERVATION) TO MONITOR OUR WATER SYSTEM. YOU MAY MAIL THE SURVEY TO - CITY OF MOUNT PLEASANT, P.O BOX 426, MT PLEASANT, TN 38474 OR DROP IN THE DROP BOX AT THE DRIVE-THRU WINDOW. IF YOU HAVE QUESTIONS, CALL 931-379-7717
Should be Empty:

WATER SYSTEM CROSS-CONNECTION SURVEY RESIDENTIAL