Backflow Protection Information Loading... Mandatory fields marked with an asterisk (*) Question Yes/No Fire System *Will the premises have a fire line? *Will there be multiple fire lines feeding the premises? *Will there be an auxiliary water supply available for fire use? *Will the premises have a sprinkler system? *Will the sprinkler system contain chemical agents (i.e. foamite)? *Will there be any form of antifreeze (including propylene glycol) introduced into the sprinkler system? *Will the fire system include a fire pump? *Will the premises have an elevated storage tank for fire protection? Domestic: *Is there an auxiliary water supply available on site? *Will the premises use reclaimed water? *Will the site have a boiler? *Will there be booster pumps or elevated tanks to aid potable water distribution? *Will the highest water outlet be more than 40 feet above the connection to the Board's main? *Will there be multiple domestic fees to the same site? *Will the premises be used for any of the following? *Medical, dental, or veterinary facilities/clinics *Mortuaries or any facility that handles remains *Animal processing facilities *Facilities with laboratories that use chemicals *Agricultural Facilities *Food or beverage processing facilities *Chemical plants *Metal-plating plants *Petroleum processing or storage facilit ies *Plants that process any radioactive materials *Car-washing facil ities Sewer: *Will the site use a pressurized sewer system of any type? Irrigation: *Will the irrigation water come from a well water source? *Will the irrigation water come from a surface water source? *Will the irrigation system include an injection port (chemicals/fertilizer)? If the above items do not describe the premises' use please do so below: Owner Information *Owner Name *Project Name *Project Engineer/Architect Name *Project Engineer/Architect Signature *Project Street Address: *Project Zip Code: *Name of Person Completing This Form: *Email of Person Completing This Form: