Residential Cross Connection Survey Form (Page 2 of 2) in pdf

Backflow Prevention Devices, Assemblies and methods must conform to the following National Standards as indicated

in WI Dept of Safety & Professional Services Chapter Comm 82.41. State plumbing code and consultant information

can be found online at:

1. ASME A112.1.2

Air Gap - The unobstructed vertical distance between the lowest point of any pipe, faucet or fixture and

the FLOOD LEVEL RIM of the receptor into which it is discharging.

2. ASSE 1011*

Hose Bibb Vacuum Breaker (for indoor use)

3. ASSE 1002*

Anti-Siphon Ball Cock for Gravity Water Closet Flush Tanks

4. ASSE 1012

Vented Dual Check Valve - For supplies to untreated boilers with less than 15 psig steam or maximum

water pressure of 30 psig.

5. ASSE 1019

Vacuum Breaker wall hydrants, freeze resistant automatic draining type

6. ASSE 1011*

Anti–Frost Hose Bibb Vacuum Breaker - For use on outside hose bibbs where it could be exposed to

freezing.

7. ASSE 1013

Reduced Pressure Principle Backflow Prevention Assembly – Requires State registration and annual

testing by a certified tester.

8. ASSE 1014

Vacuum breaker for hand held showers

9. ASSE 1001

Atmospheric Vacuum Breaker - Critical Level of AVB must be installed at least 6” above all

downstream piping and No valves downstream.

10. ASSE 1020

Pressure Vacuum Breaker - This assembly is not allowed for indoor installations. Requires State

registration & annual testing by a certified tester.

11. ASSE 1056

Spill–Resistant Vacuum Breaker - Critical Level of SVB must be installed at least 6” above all

downstream piping. Requires State registration & annual testing by a certified tester.

12. ASME A112.1.3

Air-gap Fittings for use with plumbing fixtures and appliances

13. ASME A112.18.1 Plumbing Supply Fittings

14. ASSE 1053

Dual Check Backflow Preventer Wall Hydrant Freeze Resistant Type

15. ASSE 1052

Hose Connection Backflow Preventers

*These backflow preventers can be found at hardware stores. A local plumbing permit may be required for some

installations.

**State Plumbing code may allow other devices under certain hydraulic/pumping/hazard conditions.

Cross connections identified during the survey must be corrected within ____ days of the initial survey

NOTICE:

visit. When corrective action is completed, please call #_______________________to arrange for a follow up

compliance verification survey by authorized personnel or with any questions you may have.

Customer Signature:________________________________________________Date:_________________________

Residential Cross Connection Survey Form Page 2

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