In order to protect the 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 this survey.

If you have any questions regarding this survey please contact:
Brad Paslay, Water Superintendent (217) 864-5656
________________________________________________________________________________________________________________________________
The information provided is an accurate and current description of your water system at this address. Please print your information below and sign your name as confirmation of the person completing this survey.

Question Title

* ________________________________________________________________________________________________________________________________

Question Title

* Do you have any sources of water, such as a private well, pond, lake, tank or reclaimed water that is connected to the water system? Mark all that apply.

Question Title

* Do you have a permanent in-ground lawn irrigation system installed on your property?

Question Title

* Do you have a swimming pool?

Question Title

* Is your building heated by a boiler?

Question Title

* Do you have a water powered back up sump pump?

Question Title

* Are there any backflow prevention devices installed on the premises? If yes when was it last tested?

T