Cross Connection Control Survey
Cross Connection Control Survey
City of Geneseo Cross Connection Control Survey
In order to protect the water supply from being contaminated, we are conducting a survey to determine if there are any hazardous conditions that could affect our drinking water.This survey is in accordance with Geneseo City Ordinance 53.04. Please direct any questions to City Of Geneseo Public Works Water Division at 309.944.4243.
Name
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Address
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Account Number
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Do you have any other sources of water, such as a private well, pond, lake, tank of reclaimed water that is connected to the water system?
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Yes
No
Mark all that apply
Well
Pond
Lake
Tank
Other
Other
Are there any backflow prevention devices installed on the premises?
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Yes
No
Has the device been tested?
Yes
No
Do you have a permanent in-ground lawn irrigation system installed on your property?
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Yes
No
Do you have a swimming pool?
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Yes
No
Is the pool filled by a permanent connection to water supply?
Yes
No
Is your building heated by a boiler?
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Yes
No
Do you have a sump pump?
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Yes
No
Is it connected to the sewer system?
Yes
No
Do you have a water softener
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Yes
No
The Illinois Department of Public Heath Plumbing Code requires that vacuum breakers be installed on all outdoor faucets. These devices protect the water supply from being contaminated by any substance which might enter the water hose and flow back into the system (i.e., fertilizer, herbicides, soap, etc.) Hose vacuum breakers can be purchased at most hardware stores and home and garden centers.
The information provided is an accurate and current description of your water supply at this address. By submitting this electronic form you are confirmation all information submitted in correct and accurate.
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Date
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