The Official City of Norfolk Nebraska Home Page The Official City of Norfolk Nebraska Home Page
127 North 1st St, Norfolk, NE 68701
Phone: (402) 844-2000

 

 

 

 

 

 

 

 

 

 

 

Cross Connection Control Survey Form

State Law requires consumers of public water suppliers to survey their residences not less than once every 5 years.  Completing and returning this form fulfills this requirement.  Failure to complete this form will warrant an inspection or disconnection of water service.
Do you have any of the following at your home?
  
 
1. Private well that is connected to household plumbing? Yes  No
2. Boiler Heating System? Yes  No
3. Water Softener? Yes  No
4. Swimming Pool or Hot Tub? Yes  No
5. Chemical sprayers that can be hooked to a garden hose? Yes  No
 
  Name:    
  Address:    
  *Account Number:    
  * Your Account Number is shown on your bill. Enter the complete number including punctuation. Where do I find my Account Number?  
  If you have any questions please call the Water Division at (402) 844-2210, or email Chad Roberts