Water Cross-Connection Survey

Water systems in the State of Colorado are regulated to ensure that non-potable sources of water or contamination from toxins, bacteria, and viruses do not pollute the entire water source, making people sick. The State requires that the Town (as a public water system operator) reports the number and type of cross-connections on each property that receives water from the public water system as an exercise to discover if there are cross-connections between irrigation systems and potable water lines without necessary safeguards such as backflow prevention devices, vacuum breakers, or air gaps. To that end, the Town of Silt is preparing this Cross-Connection Survey for citizens to report to the Town all potentially dangerous cross-connections.

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* 1. Name on Water Billing Account

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* 2. Account Address

Address

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* 3. Do you own or rent?

Own

Rent

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* 4. The water meter for the above account serves (check all that apply)

Residence

Garage

Other Outbuilding

Commercial Structure/Business

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* 5. Do you have any of the following? (check all that apply)

Underground sprinkler system utilizing non-potable (untreated) water

Underground sprinkler system utilizing potable (treated) water

Drip/Soaker irrigation system utilizing non-potable (untreated) water

Drip/Soaker irrigation system utilizing potable (treated) water

Auxiliary water source (well, ditch/canal)

Insecticide sprayer

Sewage dump station

Livestock water troughs

Swimming pool (either above-ground or in-ground)

Chemical irrigation system

Fire suppression system

Ghost pipes

Cleaning solution dispenser

Yard hydrant

Water softener/reverse osmosis

Hot tub

Solar array/photovoltaic

Portable dialysis machine

Onsite water storage

Chemical feed system

Water treatment system

Booster pump

Utility sinks

Boilers/Closed loop water heater

Soda machine

Ice Machine

Commercial/Industrial use of water

Car wash

Water feature, such as fountain, splash pad, or the like

Question Title

* 6. Do you have outside hose bibs at your building(s) that are used for non-potable (irrigation/landscaping) purposes?

The 2015 International Building Code requires that hose bibs be protected
**While not required by the CDPHE, it is best industry practice to protect with a vacuum breaker

Yes

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* 7. Do you have a backflow protection device on your property now?

Yes

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* 8. Do you have any water-using equipment on property that is not described above?

Yes

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* 9. If the answer to the above question is yes, please describe:

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* 10. If you marked yes to any of the above, are you aware of potential backflow prevention measures being practiced onsite, such as an air gap, check valve, or backflow prevention measure?

Yes

Water Cross-Connection Survey

Question Title

* 1. Name on Water Billing Account

Question Title

* 2. Account Address

Question Title

* 3. Do you own or rent?

Question Title

* 4. The water meter for the above account serves (check all that apply)

Question Title

* 5. Do you have any of the following? (check all that apply)

Question Title

* 6. Do you have outside hose bibs at your building(s) that are used for non-potable (irrigation/landscaping) purposes?

The 2015 International Building Code requires that hose bibs be protected
**While not required by the CDPHE, it is best industry practice to protect with a vacuum breaker

Question Title

* 7. Do you have a backflow protection device on your property now?

Question Title

* 8. Do you have any water-using equipment on property that is not described above?

Question Title

* 9. If the answer to the above question is yes, please describe:

Question Title

* 10. If you marked yes to any of the above, are you aware of potential backflow prevention measures being practiced onsite, such as an air gap, check valve, or backflow prevention measure?

Question Title

* 11. By submitting this survey, I acknowledge that the answers provided herein are accurate and true, to the best of my knowledge.

Question Title

* 12. Name of survey taker

Question Title

* 13. Date

Water Cross-Connection Survey

Question Title

* 1. Name on Water Billing Account

Question Title

* 2. Account Address

Question Title

* 3. Do you own or rent?

Question Title

* 4. The water meter for the above account serves (check all that apply)

Question Title

* 5. Do you have any of the following? (check all that apply)

Question Title

* 6. Do you have outside hose bibs** at your building(s) that are used for non-potable (irrigation/landscaping) purposes?**The 2015 International Building Code requires that hose bibs be protected**While not required by the CDPHE, it is best industry practice to protect with a vacuum breaker

Question Title

* 7. Do you have a backflow protection device on your property now?

Question Title

* 8. Do you have any water-using equipment on property that is not described above?

Question Title

* 9. If the answer to the above question is yes, please describe:

Question Title

* 10. If you marked yes to any of the above, are you aware of potential backflow prevention measures being practiced onsite, such as an air gap, check valve, or backflow prevention measure?

Question Title

* 11. By submitting this survey, I acknowledge that the answers provided herein are accurate and true, to the best of my knowledge.

Question Title

* 12. Name of survey taker

Question Title

* 13. Date

* 6. Do you have outside hose bibs at your building(s) that are used for non-potable (irrigation/landscaping) purposes?

The 2015 International Building Code requires that hose bibs be protected
**While not required by the CDPHE, it is best industry practice to protect with a vacuum breaker