Backflow Survey Form



Your NEW account number is 4 to 6 digits ling
Service Location Information






No Dashes Needed


Please indicate if your residence has any of the following:

















Not Hot Water Tanks




Not Bottled Water





If yes to ANY of the above questions, we may contact you for further information.  Furthermore, the following items will be enforced without exception:  

  • Irrigation systems require a minimum protection of a double check valve; the other items may require a higher level of backflow protection.  Contact PLC for specific requirements. 
  • The assembly can be installed by the property/home-owner, a contractor or plumber.  PLC also provides this service.  A state certified plumber must install an assembly inside the home. 
  • The assembly must meet all AWWA & State standards and appear on the most recent WSDOH List of Approved Assemblies.  You may contact PLC or WSDOH at 1-800-525-2536 for a list of approved assemblies. 
  • Assemblies shall be tested by a State certified BAT immediately after installation, relocation or repair and annually thereafter.  All results shall be reported to the Water Department within 15 days. 
  • PLC has certified BATs or you may use an outside (i.e. contractor) certified BAT.  
  • The cost of installation, relocation, annual inspections and repairs is borne by the property/home-owner. 

After the survey is returned, homeowner understands that PLC may conduct an on-site inspection of the property and/or building for cross connection possibilities.  If a cross connection is discovered, PLC will require the installation of a State-approved backflow assembly. 



Contact Information