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State Law requires the public water system to survey their consumers not less than once every five (5) years.
Completing & returning this Form, fulfills the State of Nebraska DHHS Regulation Title 179 requirement.
Failure to complete and return this Report Form to the City of Columbus, may warrant a disconnection of water service by the Columbus Wastewater Collection / Utility Division that must perform an on-site inspection before restoring service.
Can be found on your City of Columbus Utility Bill in the Billing Information section.
Account number can be found on your City of Columbus Utility Bill.Account Number Format: 123-12345-12
1. Private well that is connected to household plumbing?
If Yes, is it protected by an Approved Backflow Prevention Assembly?
2. Swimming pool or hot tub that is connected to household plumbing?
If Yes, is it protected by an air gap at the discharge hose?
4. Underground lawn irrigation system that is connected to household plumbing? (not on a well)
5. Outside threaded faucet(s) or yard hydrant(s)?
If Yes, is it protected by an Approved Backflow Prevention Assembly or Hose Bib Vacuum Breaker?
6. Chemical Sprayers connected to garden hoses?
7. Boiler heat or water to air heat pump?
8. Photo lab, chemical, medical, or other lab facility?
This field is not part of the form submission.
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