Water Use Survey Form

Do you have an irrigation system that is connected to the public water supply?*

Is your irrigation system connection protected by a RPZ valve?*

Do you have a pool that is connected to the public water supply?*

Is your irrigation system connection protected by a RPZ valve?*

Do you have a fire protection system that is connected to the public water supply?*

Is your fire protection system connection protected by a RPZ valve?*

Do you have ponds or fountains connected to the public water supply?*

Is your system connection protected by a RPZ valve?*

Do you have a private well?*

If yes, the connection must have an air gap separating the private well from the public water supply.

If a backflow device is required, is your RPZ valve inspected annually?

Name*

Account Number*

Service Address*

Street Address Address Line 2 City State ZIP Code