Lake Jackson, TX · Brazoria County
Residential Cross Connection Survey
Property owners or their authorized agents complete this survey to identify residential plumbing, equipment, and activities that could affect the city water system.
What this form is
The Residential Cross Connection Survey helps the city assess whether a residence or project may pose an increased risk of contamination to the city water system. The property owner or authorized agent describes the project, provides contact and site details, and checks applicable equipment and fixtures. The city uses the information to assess hazards and determine whether backflow protection is required.
Who needs it
A property owner or authorized agent completes the survey for a residential project or residence with plumbing, equipment, or activities connected to water.
How to submit it
Submit it to the city department named on the form; check the city website for current contact details.
About notarization
This document is signed without a notary; the signer certifies under penalty of perjury that the information is complete and accurate.
How to submit this form
- 1
Download The Survey
Download the Residential Cross Connection Survey PDF.
- 2
Complete The Form
Enter the project and owner information, check applicable equipment and fixtures, then sign and date the certification.
- 3
Gather Attachments
The form does not list any required attachments.
- 4
Submit To The City
Submit it to the city department named on the form; check the city website for current contact details.
Frequently asked questions
- Do I need a notary for the Residential Cross Connection Survey?
- No. The form has no notary block; the signer certifies under penalty of perjury that the information is complete and accurate.
- Who completes the Residential Cross Connection Survey?
- The form says it is to be completed by the property owner or their authorized agent.
- What information does the survey ask for?
- It asks for residence type, project site and owner details, a project description, and checks for equipment and fixtures connected to water.
- How do I submit the Residential Cross Connection Survey?
- Submit it to the city department named on the form; check the city website for current contact details.