2016 MCWC Cross Connection Survey

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Name of Contact (required)

Service ID (required)


Home: Cell:

Type of Service:

Residential Commercial Industrial Agricultural 

If Residential, how many in household?

 Yes No - Are you using Montgomery County Water?

 Yes No - Do you have more than one source of water?

 Yes No - Does your meter serve more than one residence or business?

 Yes No - Do you have a private well, cistern or pond?

 Yes No - Is the well, cistern or pond ever in use?
If yes, describe how:

 Yes No - Is the well, cistern or pond ever physically connected through plumbing or hoses to Montgomery County Water?
If yes, describe how:

 Yes No - Do you raise animals?

If yes, how many?
Hogs Cattle Sheep Other

 Yes No - Is Montgomery County Water used to water the livestock?

 Yes No - Do you use Montgomery County Water with your chemical spray?
What type of chemical?

 Yes No - Do you have a yard hydrant on the property?

 Yes No - Is the yard hydrant supplied by Montgomery County Water?
If no, what source?

 Yes No - Do you have a swimming pool on the property?

 Yes No - Do you have a hot tub or spa?

 Yes No - Is the pool or spa supplied by Montgomery County Water?
If no, what source is used?

 Yes No - Do you heat your home with a recirculating hot water furnace?

 Yes No - Do you have a water softener?

 Yes No - Do you have a fire protection sprinkler system?

 Yes No - Do you have any buried fuel tanks?

 Yes No - Do you have any type of back flow prevention device install on your service?
If yes, describe, including model and date of most recent inspection:

Did you make the installation yourself or was the device installed by a licensed plumber?
 Home Owner Licensed Plumber

If licensed plumber, please list name and phone number:

**Failure to respond to this survey may lead to field inspection. Thank you for your time and cooperation.

The following information is requested by the Federal Government in order to monitor compliance with Federal Laws prohibiting discrimination against applicants seeking to participate in this program. You are not required to furnish this information, but are encouraged to do so. This information will not be used in evaluating your application or to discriminate against you in any way. However, if you choose not to furnish it, we are required to note the race/national origin of individual applicants on the basis of visual observation or surname.

 I do not wish to furnish this information.


 Hispanic or Latino Not Hispanic or Latino

Race: (mark one or more)

 White Black or African American American Indian / Alaska Native Asian Native Hawaiian or Other Pacific Islander


 Male Female

This is an Equal Opportunity Program. Discrimination is prohibited by Federal Law. Complaints of discrimination may be filed with the USDA, Director, Office of Civil Rights, Washington, DC 20250-9410