(865) 577-4497

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Residential Cross-Connect Survey

Please complete the application below to disconnect service.


If you have questions regarding disconnecting service, please Email Customer Service or call during normal business hours (865) 577-4497.


Occupant Name

Occupant Email Address

Phone (999-999-9999)

Occupant Address

Occupancy (own, rent, etc.)

Meter Services Homes - How Many?

Buildings - How Many

Does The Property Have Any of the Following?

Do you have a bathroom that fills from the bottom? yes no

Do you have a water softener or any extra water treatment system? yes no

Do you have an auxillary water supply on your premises? yes no

Do you have a livestock trough or water system connected to your public? yes no

Is your home a building elevated above the meter? yes no

Is there a creek, river, or spring near or on the property? yes no

Do you have a booster/well pump or any other type of pump? yes no

Do you receive irrigation water from a different source? yes no

Do you have backflow protection device on your property now? yes no

Do you have any situation that you are aware of that could create a cross-connection? yes no

Do you have any other water equipment not mentioned above on your property? yes no








Knox Chapman Utility District
Mailing Address: P O Box 9569, Knoxville, TN 37940 | Physical Address: 1905 E John Sevier Highway, Knoxville, TN 37920
Office Hours 8:00 a.m.- 4:30 p.m. Monday through Friday
In case of emergency, call (865) 577-4497, ext. 3