City of Scottsbluff
Cross Connection Control Survey Requirement
If you need assistance completing this form, please call us at 308-630-8047.

The Nebraska Health and Human Services Regulation Title 179, and the City's Municipal Code, require consumers of our public water supply to inspect their plumbing connections not less than once every five years.

♦ If you are completing this survey for the first time, please answer all 9 questions below.
OR
♦ If this is a 5 year re-examination of your property, and no changes have been made to your plumbing connections, please answer questions 1 to 3 below, type your name at the bottom of the survey and select submit survey.

 1)  Date:       
 2)  Name:      
 3)  Location:    Telephone Number:  
    YES     NO
 4)  Do you have a private well?                                                                                                                    
   If yes, is it connected to the City's water supply?     
       
 5)  Do you have a swimming pool or hot tub connected to your plumbing?    
   If yes, is it protected by a testable backflow device?    
       
 6)  Do you have a boiler heating system or a water-to-air heat pump?    
   (NOTE: These are both different than a regular gas furnace or electric heat)    
   If yes, is it protected with a testable backflow device?     
       
 7)  Do you have an underground lawn irrigation system?    
   If yes, is it protected with a testable backflow device?    
   If you have a private well, is it strictly used for watering your yard?    
       
 8)  Do you attach chemical sprayers to your hoses such as lawn fertilizer?    
   If yes, are they protected by a hose connection vacuum breaker?    
       
 9)  Do you have a water softener or a reverse osmosis unit?    
   If yes, is the drain line permanently piped into the sewer where with a change in flow    
   and pressure, sewer water could enter your lines and contaminate your drinking water?    

  Form Completed By:  
 

Water