City of Peru Residential Cross Connection Survey

City of Peru Residential Cross Connection Survey
Name*

First NameLast Name
House Number*
Street Name*
Email*
example@example.com
Do you have any other sources of water, such as a private well or tank that is connected to the water system?

WellPondLakeTankI Don't Know
Do you have a permanent in-ground lawn irrigation system installed on your property?*
Do you have a swimming pool?*
Is the pool filled by a permanent connection to the water supply?*
Is your building heated by a boiler?*
Are there any backflow prevention devices installed on the premises? *
Has the device been tested?*
What type of water service line do you have coming into your home? (Service line before the water meter)*
Take a photo of your meter and service line.
What type of water lines do you have running throughout your home?*

GalvanizedPlasticCopperLeadI Don't Know
Do you have a sump pump?*
Is is connected to the sewer system?*
Do you have down spouts from the gutters connected to the sewer system?*
Next steps after survey completion:

The water system is required by the EPA to have a Cross Connection Control Program in place. Part of the program is a mandatory Tri-Annual Cross Connection Control Survey. This survey must be filled out by all residents and businesses connected to the water system.

If you do have a backflow prevention device installed it has to be tested/inspected annually by a plumber with a backflow prevention certification
Should be Empty: