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ChicagoRidge
Backflow Solutions
2021-03-18T09:09:26-05:00
Village of Chicago Ridge
This survey will assist to help prevent the contamination or pollution of our water resources. Please complete the form below to the best of your ability or consult a licensed plumber for assistance.
Contact Information
Name
*
First
Last
Service Address
*
Street Address
Address Line 2
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State
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Account Number
Water System Information
Please check all that apply to you
Permanent lawn irrigation system
Fire sprinkler system
Boiler
Hot tub/spa directly piped to water supply
Condo Association/HOA
Alternate water source (i.e well, pond, etc.)
Do any existing backflow prevention assemblies exist
Other equipment connections
If other connections, please specify:
Additional Information
Backflow Assembly
Manufacturer
Ames
Conbraco
Febco
Hersey
Watts
Wilkins
Other
Other Manufacturer
Model Number
Type
Size
1/2"
3/4"
1"
1 1/4"
1 1/2"
2"
2 1/2"
3"
4"
6'
8"
10"
12"
Serial Number
Do you have an additional device?
Yes
No
2nd Device
Manufacturer
Ames
Conbraco
Febco
Hersey
Watts
Wilkins
Other
Other Manufacturer
Model Number
Type
Size
1/2"
3/4"
1"
1 1/4"
1 1/2"
2"
2 1/2"
3"
4"
6'
8"
10"
12"
Serial Number
Do you have a 3rd device?
Yes
No
3rd Device
Manufacturer
Ames
Conbraco
Febco
Hersey
Watts
Wilkins
Other
Other Manufacturer
Model Number
Type
Size
1/2"
3/4"
1"
1 1/4"
1 1/2"
2"
2 1/2"
3"
4"
6'
8"
10"
12"
Serial Number
Do you have a 4th device?
Yes
No
4th Device
Manufacturer
Ames
Conbraco
Febco
Hersey
Watts
Wilkins
Other
Other Manufacturer
Model Number
Type
Size
1/2"
3/4"
1"
1 1/4"
1 1/2"
2"
2 1/2"
3"
4"
6'
8"
10"
12"
Serial Number
Do you have a multiple additional devices?
Yes
No
Please list the remaining devices you would like to include.
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