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Cross Connection Survey

EJ Water Cooperative

What is the cross connection survey?

In order to comply with EPA regulations, we are required to conduct a system survey of all members to determine if actual or potential hazards may exist. 

Additionally, the results of this survey allows us to ensure that the consumers of our public water supply are protected from the possibility of contamination or pollution arising through an improper cross-connection to the public water supply distribution system. We must have a completed survey concerning water supply usage every two years. 


Attention

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

Personal Information

We want to make sure we have your personal information all up to date.


Water Service

Answer these questions about your water service.

Service Type

Are you using EJ Water Cooperative?

Do you have more than one water source?

Does your water meter serve more than one location?

Do you have a private well, cistern, or pond?

Is your private well, cistern, or pond in use?

Has your private water source ever connected to EJ Water Cooperative water?


Agricultural

These questions are related to if and how you use your water for agricultural purposes.

Do you raise animals?

Is EJ Water Cooperative water used to water live stock?

Do you use EJ Water Cooperative with chemical spray?


Water Hydrant

It is important for us to know about your water hydrant.

Is there a water hydrant on your property?

Is the hydrant supplied by EJ Water Cooperative?


Recreational

Tell us about how you use our water for recreational purposes.

Do you have a swimming pool?

Do you have a hot tub/spa?

Do you fill the pool or hot tub / spa with EJ Water Cooperative water?


Household Utilities

Understanding the household utilities you use helps us improve the service we provide for you.

Do you heat your home with a recirculating hot water furnace?

Do you have a water softener?

Do you have a fire protection sprinkler system?

Do you have any buried fuel tank?

Do you have any type of back flow prevention device installed on your service?

Who installed the backflow prevention device?


Demographics

The following information is required by 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 wish to provide my Ethnicity, Race and Gender

Ethnicity

Race: (choose one or more)

Gender


Terms Of Agreement

I confirm that the information given in this form is true, complete and accurate and agree to the Cross Connection Survey terms of agreement