Kansas Department of Health and Environment is requiring our water district to complete customer surveys of our entire system. The purpose of the Cross-Connection Survey is to locate Cross Connections with the potable water supply. A Cross Connection is any arrangement that provides a means whereby impure water, gas or liquid may gain entrance to and contaminate or pollute a safe water supply system. Please help us keep our drinking water safe by completing this survey. 

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* 1. Is there a backflow preventer at this service?

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* 2. Are there any pumps hooked to your plumbing system? Please select all that apply:

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* 3. Do you have any of the following? Please select all that apply:

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* 4. Do you have any direct connections to the sewer? Please select all that apply:

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* 5. Any other items or contaminants on your property which could be sucked back into the water system which you would not like to drink? Please specify:

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* 6. Do you understand the hazards of backflow to household members as well as to other water system customers when there is a sudden loss of pressure or negative pressure?

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* 7. Do you understand that only a state licensed person may repair or test backflow preventers?

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* 8. Would you like a free on-site evaluation of your property?

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* 9. I understand these questions and have truthfully answered them to the best of my knowledge.

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* 10. Please Check One: 

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