RESIDENTIAL CROSS CONNECTION CONTROL SURVEY

In order to protect the City of Spring Valley water supply from being contaminated, we are conducting a survey to determine if there are any hazardous conditions that could affect our drinking water.
 
We appreciate you taking the time to complete the survey.  You may return this survey to the City Clerk’s office at 215 N. Greenwood St., Spring Valley, IL. 61362; email it to svclerk@comcast.net or fax it to (815)664-2114.  Also available at www.spring-valley.il.us to fill out online.

If you have any questions regarding the survey please contact Hal Entwistle at the Public Works Department – phone number (815)664-4752.

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* 1. The Illinois Department of Public Health Plumbing Code requires hose vacuum breakers to be attached to all outdoor faucets. These devices protect the Plumbing system from being contaminated by any substance which might enter the water hose (lawn fertilizer, herbicide, soap, etc.). Hose vacuum breakers are available at most hardware stores or through your local plumbing contractor.

The information provided in this survey form is an accurate and current description of the water system at this address. Please write your name below as confirmation of the person completing the survey:

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* 2. *Do you have any other source of water, such as a private well, pond, lake, tank or reclaimed water that is Connected to your Plumbing?

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* 3. If so has the device been tested? (If yes, please provide a copy of the test results to the City of Spring Valley 215 N. Greenwood St., Spring Valley, IL. 61362):

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* 4. *Do you have a permanent in-ground lawn irrigation system installed on your property? This does not include lawn water devices attached to a garden hose?

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* 5. *Do you have a swimming pool?

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* 6. If yes, is the pool filled by a permanent connection to the water system?

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* 7. *Is your building heated by a boiler?

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* 8. *Do you operate a business out of your home?

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* 9. Please enter your water account number: _____________________________

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* 10. Please write your name & address below as confirmation of the person completing this survey.

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