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WATER USE QUESTIONNAIRE
Surfside Homeowners Association Cross-Connection Control - Water Use Questionnaire
Name
*
First
Last
Surfside Address
*
Please enter the Surfside address for which you are filling out this form.
Street Address
Address Line 2
City
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Alaska
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Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Division
Block
Lot
Telephone No
*
Email Address
Please check any item that may apply.
If this is new construction please answer based on proposed or planned use.
Check boxes left
Irrigation or sprinkler system (not above ground hoses and sprinklers)
Fire protection sprinkler system
Yard hydrants (frost proof)
Check box jacuzzi
Jacuzzi, hot tub, spa, swimming pool
Jacuzzi sub-checks
indoor
outdoor
filled with hose
plumbed in
Sink Types
Laundry sink, utility sink, mop sink, fish or clam sink
Sink-type-sub-checks
sink faucet has threads that fit garden hose
Pond or fountain
Pond or fountain
pond-or-foundation-sub-checks
filled with hose
plumbed in
Water filter or water softener equipment
Water filter or water softener equipment
water-filter-sub-checks
under kitchen/bathroom sink
whole house system
other
RV hook up
RV hook up
number of connections:
*
Checkbox set
Water well
Dialysis equipment or other medical equipment that uses tap water
Water storage tank (not a standard water heater)
Solar heating system, radiant floor system, steam or water heating system for home (not a standard water heater)
Booster pump
Farm animals or animal watering trough
Shampoo sink or animal bathing sink
Darkroom (photo development equipment)
Dry cleaning or professional laundry equipment
Carbonated drink machine
Anti-siphon devices installed on all hose faucets
Any unusual plumbing or fixtures not standard to a house
Please provide a brief description of any other item connected to the water system on your property:
If you have a cross connection control device please provide the location on property:
Comments or Questions:
Signature
*
Name
First
Last
Date
Date Format: MM slash DD slash YYYY
Consent
*
I certify that the above information is true, correct, and complete to the best of my knowledge.
*
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Surfside Homeowners Association
Surfside Homeowners Association