Residential Cross Connection Survey Form
ADVERTISEMENT
1
2Residential Cross Connection Survey
This survey is being performed in accordance with; WI DNR 810.15, Chapter-Comm. 81, 82, 84 and the Local Municipal
Ordinance for Cross Connection Control to ensure safe drinking water.
Compliant? Yes
(no further action required
Non-Compliant
See table below for corrective action
Name____________________________________________________________________________________
Address_______________________________________ City________________________________________
Phone_________________________________________ Date of Survey _____________________________
Brochure provided in lieu of surveying normal kitchen and bathroom fixtures? Yes
Approv
Fixture Type
Location / Description
*Device
ed
ASME A112.1.2
Water Softener Drain
Y / N
Vacuum breaker tee,
ASME a112.1.3
Laundry Tub with
Y / N
ASSE 1011,1052
hose threads
Inside Hose Bibb(s)
Y / N
ASSE 1011,1052
Toilet(s)
Y / N
ASSE 1002
ASSE 1012** - Low Hazard
Boiler
Y / N
ASSE 1013** - High Hazard
ASME A112.1.2**
Humidifier
Y / N
ASSE 1012**
ASSE 1019, 1053
Outside Hose Bibb(s)
Y / N
ASSE 1011, 1052
ASSE 1001**
Lawn Irrigation
Y / N
ASSE 1020**
ASSE 1013**
ASSE 1014
Hand Held showers
Y / N
ASME A112.18.1
Water Powered Sump
ASSE 1013**
Pump
ASME A112.1.2 **
Pools / Spa /Hot Tubs
Y / N
ASSE 1001**
Kitchen Faucets
Y /N
ASME A112.18.1
Other
Other
Other
:______________________________________________________
Notes
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal