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City of Fremont - 400 E Military Ave - Fremont, NE 68025-5141
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Date
Rent or Own
Rent
Own
Service Address
Phone
Is there a private well or other source of water supply at this address including wells for geothermal heating/cooling?
Yes
No
Is there a backflow preventer in use to protect the public water supply?
Yes
No
N/A
Is there a photo lab, chemical lab, biological lab, veterinarian lab, or other chemical lab at this address?
Yes
No
Is there a backflow preventer in use to protect the public water supply?
Yes
No
N/A
Is there a boiler system used to heat this address?
Yes
No
Is there a backflow preventer in use to protect the public water supply?
Yes
No
N/A
Is there an underground sprinkler system at this address?
Yes
No
Is there a backflow preventer in use to protect the public water supply?
Yes
No
N/A
Is there a swimming pool or hot tub at this address?
Yes
No
If yes, is it filled using a garden hose faucet that has a vacuum breaker?
Yes
No
N/A
Are there outside garden hose faucets or a utility sink that a garden hose can be connected to the faucet?
Yes
No
Has a vacuum breaker been installed on each faucet?
Yes
No
N/A
Is there a water softener system at this address?
Yes
No
Is there an air gap between the hose and the drain?
Yes
No
N/A
Are there other suspected backflow conditions at this address?
Yes
No
Please list any general questions or comments regarding drinking water quality or utility service.
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