Residential Cross Connection Plumbing Survey

Please complete all fields and press "Submit" when complete.

If you have questions please contact 402-441-5912, or email at ctaylor@lincoln.ne.gov. Thank you for assisting in compliance with State of Nebraska public water supply regulations and protecting Lincoln's drinking water.

Contact Information (please include at least one)

Please complete survey even if no cross connections are present.

Plumbing Cross Connection Type
1.Is there a private well or other source of water supply at this address including wells for geothermal heating/cooling source?
If yes, is there a backflow preventer in use to protect the public water supply?
2.Is there an underground lawn irrigation system at this address?
If yes, is there a backflow preventer in use to protect the public water supply?
If yes, does the irrigation system have a pump?
If yes, does the irrigation system have a chemical or fertilizer system attached to it?
3.Is there a swimming pool or hot tub at this address?
If yes, is there a backflow preventer in use to protect the public water supply?
4.Is there a photo lab, chemical lab, biological lab, veterinarian lab, or other chemical lab at this address?
If yes, is there a backflow preventer in use to protect the public water supply?
5.Is there a boiler system used to heat the home at this address?
If yes, is there a backflow preventer in use to protect the public water supply?
If yes, are chemicals used in the water?
6.Is there medical, dental or dialysis equipment used at this address?
If yes, is there a backflow preventer in use to protect the public water supply?
7.Are there other suspected plumbing cross connections at this address? See Brochure
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