Mill Creek Water Reclamation District Survey


Water system survey information can be entered into the form below.
Please enter all information as truthfully and accurately as possible.

*All items are required

Customer Information

Name on Account	* required
Address	* required
Unit/Apt. #
City	* required
State	* required
Zip	* required
Water Account #	* required
Phone	* required

Survey Information

Which of the following items are located at this specific water account? (You must select either "yes" or "no" for each item.)
Private well or water source?	yes no * required
Boiler?	yes no * required
Permanent lawn irrigation system?	yes no * required
Swimming pool directly piped to public water supply?	yes no * required
Hot tub or spa directly piped to public water supply?	yes no * required
Fire sprinkler system?	yes no * required
Climate control system using water?	yes no * required
Other equipment or connections?	yes no * required
If other equipment or connections, please specify:

YOU MUST CHECK THIS BOX TO INDICATE ACCURACY:   I certify the above information is truthful and accurate to the best of my ability.*

Please enter Captcha in the box below (MUST BE IN ALL CAPS)  required  * * What's This? Please enter Captcha Phrase.