Consolidated Utility District is required by TN Department of Environment and Conservation to have this completed form on file.
Definitions
Backflow: The reversal of the intended direction of flow of water or
mixtures of water and other liquids, gases, or other substances into the distribution pipes of a potable water system from any
source.
Cross-Connection:Any physical arrangement whereby public water supply is
connected, directly or indirectly, with any other water system, sewer, drain, conduit, pool, storage reservoir, plumbing fixture or other
device which contains, or may contain, contaminated water, sewage, or other waste or liquid of unknown or unsafe quality which may be capable
of contaminating the public water supply as a result of backflow caused by the manipulation of valves, because of ineffective check valves or
backpressure valves or because of any other arrangement.
2.) This meter serves:
Homes, how many?
Buildings, how many?
3.) Do you have(check all that apply):
4.) Do you have a water softener or any other treatment system?
5.) Do you have livestock and use a watering trough or watering system?
6.) Do you have an auxilary water supply on your premises?
7.) Do you receive irrigation water from a different source?
8.) Do you have a backflow device on your property now?
9.) Do you have any other water using equipment on your property not mentioned above?
If yes, please describe here: