THIS SURVEY IS FOR ARCATA AND JACOBY CREEK ONLY. IF YOU ARE NOT IN THESE AREAS, DO NOT SUBMIT THIS SURVEY.

Please complete the questionnaire below so that we can determine the level of cross-connection protection your service connection requires

Property Owner First and Last Name*

Street Number and Name*

City, State, Zip*

Phone/Cell Number

Email Address (optional)

Do you have any of the following on your property? (check all that apply)*

In-ground irrigation Drip irrigation system Above ground storage tank(s) Swimming pool Spa/Hot Tub Fire sprinkler system with chemical or antifreeze injection capability Fire sprinkler system without chemical or antifreeze injection capability (water only) Photo Lab

Sewage Booster Pump Boiler Sump Pump Private Well (in use) Private Well (not in use) Private Well (disconnected/capped/not in use) None of the above

I certify that the information provided is accurate to the best of my knowledge and understand that incorrect or incomplete information may result in additional review or required corrective actions by the City. If you are unsure how to answer any question, please contact the City for assistance before submitting the form.*

AGREE