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2. Please complete the survey below to update the Village's records about cross connections and/or backflow devices on your property. If you prefer to download and mail/email our form, you may do so here. Forms may be sent to rpz@winnetka.org.

4. Name of business or homeowner*
6. Address*
8. Phone Number
10. Email Address*
12. Property Type*

    1. Residential
    2. Commercial
    3. Other
13. Occupancy*

    1. Owner
    2. Tenant
    3. Other
15. Type of building*

    1. Single family home
    2. Single-story commerical
    3. Multi-unit home, condo, or townhouse
    4. Multi-story building (2 or more floors)
    5. Other
16. Do you have any of the following on your property? (Check all that apply)

    1. Swimming pool
    2. Fire sprinkler sytem
    3. Lawn sprinkler system
18. Do you have a backflow preventer on your property now?*

    1. Yes
    2. No
    3. Don't know
19. If yes, date last tested
    If yes, date last tested
21. If yes, where is it located?
23. Comments:
Leave This Blank:


25. 1. Receive an email copy of this form.
26. Email address

    This field is not part of the form submission.

27. Submit

* indicates a required field