2. First Name*
3. Last Name*
5. Address1*
7. Address2
9. City*
10. State*
11. Zip*
13. Occupany

    1. Own
    2. Rent
14. Meter Serves

    1. Homes
    2. Buildings
15. How many?
    -- Select One --12345
17. Do you have any of the following?

    1. Hot tub
    2. Swimming Pool
    3. Jacuzzi
    4. Waterbed
    5. Solar System

    1. Greenhouse
    2. Underground Sprinkler System
    3. Darkroom Equipment
    4. Drip/Soaker/Irrigation System
    5. Portable dialysis machine

    1. Insecticide Sprayers (that attach to garden hose)
    2. Utility sink with threaded faucet
    3. Woodburning hot water heater
    4. Ghost pipes (unidientified)
19. Do you have a bathtub that fills from the bottom?
    -- Select One --YesNo
20. Do you have a water softener or any extra water treatment system
    -- Select One --YesNo
21. Do you have an auxiliary water supply on your premises?
    -- Select One --YesNo
22. Do you have livestock and use a water trough or water system connected to by public water?
    -- Select One --YesNo
24. Is your home or building elevated above your water meter?
    -- Select One --YesNo
25. Do you have hobbies that require extensive amounts of toxic chemicals (taxidermy, metal plating, biodiesel, ethanol production, etc.)
    -- Select One --YesNo
26. Does a creek, river, or spring water run near or on your property?
    -- Select One --YesNo
27. Do you have a booster pump, well pump, or any other type water pump?
    -- Select One --YesNo
29. Do you receive irrigation water from a different source?
    -- Select One --YesNo
30. Do you have a backflow protection device on your property now?
    -- Select One --YesNo
31. Do you have any situation that you are aware of that could create a cross-connection?
    -- Select One --YesNo
32. Do you have any other water-using equipment on your property not mentioned above?
    -- Select One --YesNo
34. If yes, please list below.
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36. 1. Receive an email copy of this form.
37. Email address

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38. Submit

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