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2. First Name*
3. Last Name*
5. Address1*
7. Address2
9. City*
10. State*
11. Zip*
13. Phone Number*
14. E-mail Address*
16. Are you the property owner?

    1. Yes

    1. No
18. Owner Name
20. Owner Address1
22. Address2
24. City
25. State
26. Zip
28. Owner Phone Number
29. Owner E-mail Address
31. Number of units on property*
33. Please indicate which of the following you have:
35. Alternate Water Source*

    1. Yes

    1. No
36. If yes, please indicate which source you have

    1. Well
    2. Cistern
    3. Reclaimed Water (Excluding Rain Barrels)
38. Boiler or Steam Heat*

    1. Yes

    1. No
39. If yes, please indicate boiler type

    1. Residential
    2. Commercial (+200,000 BTU/hour)
    3. Not Sure
41. Fire Sprinkler Protection System*

    1. Yes

    1. No
43. Lawn Irrigation System*

    1. Yes

    1. No
45. Shampoo Bowl/Sink*

    1. Yes

    1. No
47. Swimming Pool/Hot Tub*

    1. Yes

    1. No
49. If yes, how do you fill your pool/hot tub?
51. Other Equipment with a Direct Connection to City Water*

    1. Yes

    1. No
53. If yes, please indicate what equipment connects to City Water.
55. Do you have backflow preventers on your property?*

    Backflow Preventer

    1. Yes

    1. No

    1. Not Sure
57. Pictures of devices in question can be e-mailed for review by the City’s Plumbing Inspector. The City’s Plumbing Inspector can also be contacted via phone at 309.524.2374.
59. Installation Date
60. Serial Number
62. Size
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64. 1. Receive an email copy of this form.
65. Email address

    This field is not part of the form submission.

66. Submit

* indicates a required field