Welcome to the City of Chillicothe

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Name:
Address:
City or Town:
State
Zip or Postal Code:
County:
Email:
How many kitchen sinks do you have?	One	Two	Three or More	None
How many kitchen faucets with a sprayer do you have?	One	Two	Three
How many ice makers do you have?	One	Two	Three
How many garbage disposals do you have?	One	Two	None
How many bathroom sinks do you have?	One	Two	Three or more
How many bathtubss do you have?	One	Two	Three or more	None
How many hot tubs do you have?	One	Two or more	None
How many toilets do you have?	One	Two	Three or more	None
How many boilers do you have?	One	Two	None
How many outside faucets do you have?	One	Two or more	None
How many non-freezing type outside faucets do you have?	One	Two or more	None
Do you have any permanent lawn irrigation systems?	Yes	No
Do you have a lawn fertilizer system?	Yes	No
Do you have a high pressure washer?	Yes	No
Do you have a private well?	Yes	No
If yes, is the private well physically connected to the water system?	Yes	No
Do you ahve any other helpul information regarding use of water?	Yes	No

Cross Connection Survey