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Cross-Connection Control Survey
Cross-Connection Control Survey
Nebraska’s Safe Drinking Water Act requires consumers of public water systems to survey their residences not less than once every 5 years. Completing and submitting this form fulfills this requirement. Failure to complete this form will warrant an inspection or disconnection of water service.
Please enable JavaScript in your browser to complete this form.
Customer Information
Name:
*
First
Last
Business Name: (if applicable)
Email
*
Address
*
Address Line 1
Address Line 2
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Zip Code
Account Number:
*
Your Account Number is shown on your utility bill or you may contact City Hall at 402-694-6992 for assistance.
Survey Questions
1. Is this a Commercial or Residential water service?
*
Commercial
Residential
2. Is there an underground lawn irrigation system installed and/or in use?
*
No
Yes, It is protected by a testable backflow preventer.
Yes, It is NOT protected by a testable backflow preventer.
Yes, But it is not in use.
3. Is there a water softener installed and/or in use?
*
No
Yes, It is protected by an air gap.
Yes, It is NOT protected by an air gap.
Yes, But it is not in use.
4. Is there a private well located and/or in use on this property?
*
No
Yes, It is used for underground lawn irrigation system only.
Yes, It is our primary domestic water source.
Yes, But it is not in use.
5. Is there a swimming pool or hot tub installed and/or in use?
*
No
Yes, It is protected by a testable backflow preventer.
Yes, It is NOT protected by a testable backflow preventer.
Yes, It is not in use.
Submission Date
*
I have completed the above survey truthfully, and to the best of my knowledge. I have listed all water uses at my facility that could potentially create a hazard to the public water supply.
*
I Agree
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