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Water Use Questionnaire
 

Name*

Service Address*

City*

State*

Zip Code*


Mailing Address (If different than service address)

City

State

Zip Code


 
Please indicate whether the special plumbing or activities listed below apply to your premises.
 

Yes

           No
Underground sprinkler system
Water treatment system (e.g., water softener)
Solar heating system
Residential fire sprinkler system or suppression system
Private well or other water supply (whether or not connected to plumbing system)
Sewage pumping facilities or grey water system
Boat moorage with water supply
Live stock watering and/or animal watering troughs
Swimming pool or spa
Greenhouse
Decorative pond
Photo lab or dark room
Medical equipment connected to water supply
Home-based business.
If Yes, list type/describe (e.g., beauty salon, machine shop, etc.):
  • Irrigation systems require a minimum protection of a double check valve; the other items may require a higher level of backflow protection. Contact office for specific requirements and/or if you plan to install an irrigation system.
  • The assembly must be installed by the property/home-owner or by a licensed plumber.
  • The assembly must meet all AWWA & State standards and appear on the most recent Washington State Department of Health (WADOH) List of Approved Assemblies.
  • Assemblies shall be tested by a State certified Backflow Assembly Tester (BAT) immediately after installation, relocation or repair. In addition, an annual test shall be performed. All results shall be reported to H&R Waterworks, Inc. within 15 days. (This is not required if you are currently enrolled in H&R’s Cross Connection Control Program.)
  • The cost of installation, relocation, annual inspections and repairs is borne by the property/home-owner.

Homeowner understands that H&R Waterworks, Inc. may conduct an on-site inspection of the property and/or building for cross connection possibilities. If a cross connection is discovered, H&R Waterworks, Inc. will require the installation of a State-approved backflow assembly.

I certify that I am an authorized signer for the water account*

Completed by*

Email Address*
 

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