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3. City of Fremont Cross Connection Water Survey

   State  law  requires  consumers  of  public  water suppliers to survey their residence not less than once every 5 yrs. Completing & returning this form fulfills this requirement. Failure to complete this form will warrant an inspection of your water services.

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6. Date:*
7. Name:
9. Address:*
10. Rent or Own:
11. Phone Number:
13. 1) Is there a swimming pool or hot tub at this address?

    1. Yes
    2. No
15. 2) Is there an underground sprinkler system?

    1. Yes
    2. No
17. 3) Is there a boiler system used to heat this address?

    1. Yes
    2. No
19. 4) Is there a water softener system at this address?

    1. Yes
    2. No
21. 5) Is there a private well or other source of water supply including a well for geothermal heating/cooling?

    1. Yes
    2. No
23. 6) Is there a photo lab, chemical lab, biological lab, veterinarian lab, or other chemical labs at this address?

    1. Yes
    2. No
25. 7) Are there outside garden hose faucets or a utility sink that a garden hose can be connected to the faucet?

    1. Yes
    2. No
27. Plumbing Cross Connections

    A cross connection is any actual or potential link between a public water supply and a source of contamination. Every property has potential cross connections, which can lead to serious health hazards if backflow occurs. Backflow happens when water flow reverses due to a sudden drop in pressure, often caused by heavy usage, fire hydrant operation, or a broken water main. You can prevent backflow, and contamination, from happening to your water supply by installing a backflow prevention device. Common backflow prevention devices include: 

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31. Thank you for helping to protect the public drinking water in our community. FREMONT WATER SYSTEM - 400 EAST MILITARY AVE - FREMONT, NE 68025
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