2016_0519 CITY aF C(iPPELL WATER UTILITIE5
CUST4MEIt SERYICE TNSPE�TI�ri�
Residentiat � Commercial ❑ TNRCC�D#a57QU4fl
���._-�t��� �!� � �'� , upan inspection of the prn•ate vrater disrribution facilities loca€ed at
� �+ �' �� �.-,w}zich is connected to khe Gity of Cappell Water System, do hereby certify
that,ta the best of my knowtedge:
In Nan- N/A
Comptiance Compliance
(1) Na dizect connectian beiwe�n the pubiic drinlcing water s�pply and a pot+�ntial � p �
s4urce o€corttarnination exists. PoYerttial sourees pf contamination are isolated
€rom the pubiic watc�r system by an a�gag or an appropriate back#Iaw prevention
assernbly in a�cordan�e with Gammissian regula3ions.
(2) No�ross-connection between tlte public dri�ing water suppty and a pnvate water '� p �
system exists. Where an actuaI air g�p is not maintained between the publie water
supply aud private water sugpiy, an approved. reduced pzessure-zcane b�cl�flow
prevention assembly is praperly instat�ed and a service agreernent exists for
annual inspection and tesring by a certified backflow prevention device tester.
(3) No connection exists which wauid allow the retum of water used far candensing � p �
coc�ling or indns�ial pracesses back to the pub}ic water supply,
{�) Na pipe or pipe�tting which cantains rnore than 8.0%0 lead exists ixs private water p �
distribution;faciIities installed on vr after July l, 1988. �
(5) No solder or fli:�t�cc which cont�ins more ikhan U.2°fo lead exists in private water '�g'j p �
distribu�ion facilities inst�lled on ar after 3uly l, 198$.
Water senrice shall not be provided ar restored to the private water distribution facilities until the abave condirions are determined to be
in campliance.
T certify tt�at the following mater�sls will�as used in the installation of ttie private water distribution facilities Iocated at
and that the inspector will validate compliance dwing the inspection process:
Service lines Lead CI Copger ❑ PVC � Other "�. ��,;3C
Sol er Lead ❑ Lead Free ❑ Salvent Weid Cl Other �
I rscognize that this docum�nt shall become a pexmaaent zecord of the aforementicrosd Public Watar System and that I am legally
resp 'ble for the vaI'rdity of the inforrnation I have provided.
� ��:� t;� > � � �S '�
Signa re of Licensed Ptumber Reg�stratton Number
�.r� � �Y-- ,g_ ,��,
Type of Re stration 17ate
I recognize that this dc�cument shall becorne a permanent xecord of the aforementioned Public Water System and that I am legally
resp ibie for the validity of'the inforrnat� n prov'de�,
� `�J ' � ��� �
Sign re of Inspector Rcgistration Number
.-1.�'�c.D � � f�'-/�
Type af Rcgis tion Date
Whltt-CustamefS Ca�Y }'ellow-Ciry"s CoPY
Pink-Inspeaafs Gspy