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2. First Name
3. Last Name
5. Service Address:*
6. Email Address:*
8. Do You Own The Property?*

   1. Yes
   2. No
10. Best Contact For Backflow/Maintenance Inquiries?

    Please Include Name, Phone, Email

11. Type of Service:*

    Check any that apply

    1. Residential
    2. Commercial
    3. Commercial - Office & Restrooms Only
    4. Industrial
    5. Agricultural
    6. Other Type of Non-Residential
13. Indicate which of the following are used at this service address.*

    Check all that apply

    1. Underground Lawn Sprinklers
    2. Swimming Pool and/or Jacuzzi/Hot Tub
    3. Fire Sprinkler
    4. Water Powered Sump Pump Backup
    5. Frost Free Yard Hydrant
    6. Booster Pump
    7. Water Recirculating System or Pump

    1. Auxiliary Water System (Private Well, etc.)
    2. Cooling Tower
    3. Water Storage Tank
    4. Solar Heating System
    5. Any Type of Water Treatment Equipment
    6. Hot Water or Steam Boilers
    7. Utility Sink with Threaded Faucet

    1. Mop Sink
    2. Pressure Washer
    3. Laboratories
    4. Portable Dialysis Machine
    5. Metal Processing
    6. Antifreeze Flush Kit

    1. Greenhouse
    2. Insecticide Sprayer (Attached to Garden Hose)
    3. Water Trough For Livestock
    4. Spray Tanks For Farming
    5. None of the above - Office & Restrooms Only
    6. Other (Add items below)
15. List any items at this address not listed above
16. Have any of these items been installed on your property in the past 12 months?*

    1. Yes
    2. No
18. Water Meter Size*

    Select any that apply if you have multiple

    1. 3/4"
    2. 1"
    3. 1.5"
    4. 2"

    1. 3"
    2. 4"
    3. 6"
19. Service Line Material*

    Private Side - From City Right of Way to Dwelling

    1. Polyethylene (Poly)
    2. PVC
    3. Copper

    1. Galvanized
    2. Other
21. Do you have a testable backflow preventor on your property?*

    1. Yes
    2. No
22. Have any changes been made to your water plumbing in the past 5 years?*

    1. Yes
    2. No
24. To the best of your knowledge has the City of Avon Utilities Department ever conducted an onsite backflow survey of your property?*

    1. Yes
    2. No
26. Comments
28. I hereby certify that I am the owner of the above listed property or am authorized to act on behalf of the owner and that all information provided is true, complete, and correct to the best of my knowledge.*

    1. Yes
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29. 1. Receive an email copy of this form.
30. Email address

    This field is not part of the form submission.

31. Submit

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