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Cross Connection Control Survey

  1. The following form is to be used by water department personnel and/or by customers of the Village of Rantoul public water supply. Data from this form may b used to determine if the property should be inspected by a licensed plumber with a CCCDI certification to detect and correct any cross-connections found on the property.

  2. Kitchen:

  3. Bath:

  4. Other:

  5.  

  6. Is/Are private well(s) physically connected to the water system?

  7. Is/Are private well(s) physically connected to the water system?

  8. Leave This Blank:

  9. This field is not part of the form submission.