Backflow Survey

    Cross-Connection Control Survey Form

    Nebraska Department of Health, Title 179 Regulations requires that every facility connected to a public water supply, be surveyed for cross-connections once every five years. This regulation requires the “customer” to complete this survey and report the results to their Water Department. In order to assist you, we have developed the following form. Completing and submitting this form will fulfill the Nebraska Department of Health’s requirement.

    The revised EPA LEAD & COPPER RULE requires all water service lines be identified. Please identify the type of service line that feeds water to your Home or Business.
    1. What is the Water Service used for at this facility?
    2. Is there a Backflow Prevention Device at this facility? YesNo
    3. Is there an underground Sprinkler system at this address? YesNo
    4. If there is a sprinkler system, is the system connected to City Water? YesNo
    5. Is there a private well on this property? YesNo
    6. If there is a well, is it being used? YesNo
    7. Do you have a Water Softener? YesNo
    8. Do you have a swimming pool? YesNo
    9. Do you have Boiler heat or water to air heat pump? YesNo

    If you have any questions please contact your Water Protection Specialist, Christopher Holley, at 308-535-6740 Ext. 6