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

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* 3. Do you own or rent?

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

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

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* 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

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

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

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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?

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

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* 12. Name of survey taker

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* 13. Date

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