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Residential Backflow Assembly Survey

The Village of Schaumburg is dedicated to delivering safe and clean drinking water to your home. An important part of this is ensuring the effective control of cross-connections. A cross-connection is a point where your water supply pipe comes into contact with a source that could contaminate the water. Lawn irrigation systems, fire sprinklers, hot tubs/spas and in ground pools are examples of potential cross-connections. If left unprotected, cross-connections may allow contaminants or pollutants to enter the water system through a backflow. Backflows occurs when a drop in water pressure causes water to flow in the opposite direction, increasing the potential for contaminated water to flow back into the system.

To ensure the integrity of the water supply, the village has an established Cross-Connection Control program in compliance with Illinois Environmental Protection Agency (IEPA) requirements. A component of this program is a triennial survey of village properties to ensure potential cross-connections and backflows aren’t present.

Your participation in a voluntary survey of your property will help determine where cross-connections may exist. Thank you in advance for your assistance.

Water system survey information can be entered below. Please enter all information as truthfully and accurately as possible.

Full Name

Full Address

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System Information

Check all items that are at your property.

Do any existing backflow prevention assemblies exist?

Section 3 of 5 in this document

Device Manufacturer Information

Permanent Lawn Irrigation System

Fire sprinkler system

Boiler

Hot tub/spa/pool directly piped to water supply

Condo Association HOA

Alternate water source (i.e. well, pond, etc.)

Other equipment connections

Existing Backflow Prevention Assemblies

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