TOWN OF SMYRNA  -  CROSS-CONNECTION CONTROL SURVEY

What is a Cross-Connection Control Program?  (pdf) 

A cross-connection is any actual or potential physical connection between a public water system or the consumer’s water system and any source of non-potable liquid, solid, or gas that could contaminate the potable water supply by backflow.

1) Property Address

2) Property Type       Residential           Commercial     Own      Rent

    3) This meter serves   Home (s)     How many (rentals/apts.)?     Buildings    How many

    4) Do you have? (Check all that apply)

                Swamp Cooler               Hot Tub                                  Swimming Pool         Solar System

                Jacuzzi                           Underground Sprinkler System  Greenhouse             Ghost Pipes (unidentified piping)

                Fire Sprinkler System    Drip Irrigation System                Water Bed

5) Do you use? (Check all that apply)

                Anti-freeze Flush Kits                         Insecticide Sprayers (that attach to a garden hose)

               Darkroom Equipment                         Portable Dialysis Machine  

6) Do you have a water softener or any other treatment system connected to your water system? 

 YES   No 
7) Do you have an auxiliary source of water, such as a private well, at this address? YES   No 
8) Do you have livestock and use a water trough? YES   No 
9) Is your home or building elevated above your water meter? YES   No 
10) Does a creek, river or spring run on or through your property? YES   No
              - If yes, do you pump or draw water from this source? YES   No 
11) Do you have a booster pump, well pump or any other type of water pump? YES   No
12) Do you receive irrigation water from a different source? YES   No
13) Do you have a backflow preventer on your property now? YES   No 
14) Do you have any situation that you are aware of that could create a cross-connection? YES   No 
15) Do you have any other water using equipment on your property not mentioned above? YES   No

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