Town of Chilhowie

Water Works

Questionnaire

Name:    ­­­­­­­­­­­­­­­­­          ___________________________________________________________

Address:          ___________________________________________________________

Home Phone:  _____________________                  Work Phone:  _________________

Property Owner if not current resident:

Name:             ____________________________________________________________

Address:         ____________________________________________________________

Telephone:  ___________________________

Please check items that are located at this premise:

___ outside spigots without vacuum breaker                                      ___ swimming pool

___ animal watering trough                                                    ___ shampoo bowl/sink

___ private well, spring, or cistern                                        ___ baptismal pool             ___ darkroom/ photo development                                       ___ dye vat

___ frost-proof spigot with vacuum breaker                            ___ fish pond

___ lawn irrigation sprinkler system                                      ___ pressure booster pump

___ fire protection sprinkler system                                       ___ solar heating system

___ mop sink/laundry sink/utility sink with hose bib threads   ___ pressure washers

___ steam or hot water heating system                                              ___dialysis equipment

___ carbonated drink machine                                                             ___ water storage tank

___ yard hydrant/yard spigot/standpipe                                 ___ pressure washers

Please provide a brief description of any other devices or treatment units connected to the water system on your property:

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please check the cross control devices that you know are installed on your property and list any others that are not listed below:

_____Check valve                              _____ Backflow Preventor

_____ Double Check valve                _____ Reduced Pressure Zone

_____ Other: ____________________________________________________________

AdditionalComments_____________________________________________________________________________________________________________________________________________________________________________________________________

Please return this for to:                               

Town of Chilhowie                  Or you may return it to the Town Hall or the Drop Box at

P.O. Box 5012                                    the Town Hall

Chilhowie, VA 24319 

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