North Bend, WA · King County
Cross-Connection Residential Survey Questionnaire
This questionnaire helps North Bend Water Department assess possible cross-connections at a residence after a plumbing permit application.
What this form is
The City of North Bend requires this questionnaire when a plumbing permit has been applied for at the address. It asks about property ownership, plumbing and water systems, equipment, and other conditions that could create a cross-connection with the city’s water supply. The form is for preliminary assessment; the water purveyor may require a more thorough assessment later.
Who needs it
The applicant or property owner must complete it when a plumbing permit has been applied for at the residence.
How to submit it
Return the completed form within five business days of plumbing permit issuance to the North Bend Water Department, 920 SE Cedar Falls Way, North Bend, WA 98045, or email it to [email protected].
About notarization
This questionnaire is signed and dated without a notary; the signer completes the name and date fields, and the form mentions no notarized or sworn attachment.
How to submit this form
- 1
Download The Questionnaire
Download the Cross-Connection Residential Survey Questionnaire.
- 2
Complete The Questions
Provide applicant and property information, answer the questions about the residence, and add comments if needed.
- 3
Sign And Date
Complete the name and date fields on the form.
- 4
Submit To The Water Department
Return the completed form within five business days of plumbing permit issuance by mail or email to the Water Department.
Frequently asked questions
- Do I need a notary for the Cross-Connection Residential Survey Questionnaire?
- No. The questionnaire is signed and dated without a notary, and it does not mention any notarized or sworn attachment.
- Who must complete this questionnaire?
- The city asks for it when a plumbing permit has been applied for at the address. The applicant or property owner provides information about the residence and its water systems.
- How do I submit the Cross-Connection Residential Survey Questionnaire?
- Return it within five business days of plumbing permit issuance to the North Bend Water Department at 920 SE Cedar Falls Way, North Bend, WA 98045, or email [email protected].
- What information does the questionnaire ask for?
- It asks about ownership, possible cross-connection sources and equipment at the property, water supplies and pumps, and any other situation that could create a cross-connection.
Need something notarized?
This Cross-Connection Residential Survey Questionnaire doesn’t need a notary — but if you have another North Bend form that does, a commissioned online notary can help.