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Cross-Connection Control Survey

Residential Water Usage

In compliance with Washington State Department of Health requirements (WAC 246-290-490), Blalock Orchard District 10 carries out a program of Cross Connection Control that helps protect your drinking water from contamination. A cross connection is any actual (or potential) physical connection between a potable (drinking) water pipe and any other pipe, system, or machine that contains non-potable fluids, where those substances could find their way into the drinking water system. Such an event is called a “backflow.” Backflows are preventable — sprinkler systems are the most common residential hazard.

This survey is being conducted so we can inventory sites that are a potential cross connection hazard and work with property owners to prevent backflows. Please complete and return this survey. If you do not have any of the listed cross connections, please still complete the form by simply marking “None of the Above.” It is vital that we receive a response from each customer. If a completed survey is not received, you may be required to install a backflow preventer assembly on your side of the meter within ninety (90) days and have it tested, or water service may be subject to disconnection. Device requirements for a home-based business will be determined based on hazard.

Please indicate if your residence has any of the following

Check all that apply.

Backflow Prevention

If yes, please provide the following and attach a copy of the latest test form below.