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 returning this form will fulfill the Nebraska Department of Health’s requirement.

You may mail the completed form to P.O. Box 490, North Platte Nebraska 69103, drop it by at 201 W 3RD ST, E-mail it to or fax it in to (308)-535-6748

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