Jefferson Water and Sewer District

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Backflow Survey

Name:

Address:

Phone:

Email:

1. Do you current have a backflow preventor at your property?

Yes

1.a If yes, how many do you have?

1.b Please list the brand, model, and serial number of each device.

2. Do you have any of the following on your property? (Check all that apply)

a. Sprinkler

b. Pool (Permanent above or below ground)

c. Hot Tub

d. Well, pond, or other auxiliary water system

e. System of process fluids

f. Other potential cross-connection to the Public Water Supply

None of the above

Please explain if "f. Other potential cross-connection to the Public Water supply" was selected.

3. If you did not check boxes A-F on question 2, you are not required to have a backflow preventer. If you are not required to have a backflow preventer and you answered YES to question 1, do you plan to remove the backflow preventer or keep it in place?

Keep

Remove

I checked NO on question 1

By clicking submit survey below, you affirm that the information provided in response to this survey is truthful and accurate to the best of your knowledge.

Acknowledged

Thank you for submitting your backflow survey. If you need further assistance, please contact us at customerservice@jwsd.org

Oops, there was an error sending your survey.

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The District is happy to discuss your circumstances with you to determine whether you are required to have a backflow preventer. Please feel free to contact us by calling (614) 864-0740, between 8am-5pm, Mon-Fri. If we can’t make a determination after speaking with you, we will schedule a time for our technician to visit your residence to make a determination.

Find Us

We would be happy to answer any questions you have.
Contact Us

6455 Taylor Rd, Blacklick OH 43004-9600

Call Us: (614) 864-0740

Email Us: customerservice@jwsd.org

Business Hours

Mon - Fri: 8:00 am - 5:00 pm
Sat - Sun: Closed

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Backflow Survey

We would be happy to answer any questions you have. Contact Us

Business Hours

We would be happy to answer any questions you have.
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