High Gabriel Water Supply Corporation

P.O. Box 2799

Cedar Park, Texas 78630

Service Inspection Affidavit

I do hereby swear that on ___________ 20___ I personally inspected the private plumbing facilities located at ________________________, Leander, Texas. Furthermore, knowing that these private plumbing facilities will be connected to High Gabriel Water Supply Corporation, public drinking water system ID # 2460027 serving said location, I swear to the best of my knowledge that the following conditions are true:

(1)  No direct connection exists between the public drinking water supply and any potential source of contamination.

(2)  That any potential sources of contamination, including but not limited to irrigation (sprinkler) systems, private water wells, heat exchange systems, or any pressurized water treatment devices, are isolated by either:

(a)  air gap




(b)  a reduced pressure-zone backflow prevention device, installed and maintained by annual service contract by a State of Texas certified backflow prevention inspector.

(3)  No connection exists which would allow the return of water used for condensing, cooling, or industrial processes back to the public water supply.

(4)  No pipe or pipe fitting containing more than 8.0% lead was used.

(5)  No solder or flux containing more than 0.2% lead was used.

(6)  All plumbing fixtures installed are in compliance with the latest plumbing codes of the State of Texas.

I further certify that: (1) the service line between the public water supply and the private plumbing facilities is ____ inches diameter and made of ___________ (e.g. PVC, copper, etc.); (2) is not within 10 feet of any on-site wastewater disposal system; (3) all joints in this line are connected using ____________________ ; and, (4) a City of Austin approved property owners cut-off valve is installed inside of the meter box.

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Signature of Inspector

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Registration Number