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2. Please complete this form for each building/property you own within the City of Dyersville. Forms need to be completed by July 1, 2023.
4. Property Owner Name:*
6. Property Owner Address:*
8. Phone Number:*
9. Email Address: *
11. Year Service Line Installed:*

    (if original line, the date the house/business was built)

12. Information to help determine what type of service line you have.
    Click here.
14. Were lead pipes ever installed at this property? *
    -- Select One --YesNoUnknown
15. Current service line material?*
    -- Select One --LeadGalvanizedCopperPlasticOtherUnknown
17. Do you have a water sofener?
    -- Select One --YesNoUnknown
19. Do you have a filter system?
    -- Select One --YesNoUnknown
20. If you have a filter system, what type do you have?
    -- Select One --Whole houseOn faucet Reverse osmosisUnknown
22. What type of interior plumbing do you have?

    1. Lead
    2. Galvanized
    3. Copper
    4. Plastic
    5. Other
    6. Uknown

    check all that appy

24. Has your interior plumbing ever been updated?
    -- Select One --YesNoUnknown
25. If your interior plumbing has been updated, when?
    -- Select One --Before 1989Between 1989 & 2014After 2014Unknown
27. Photo of main interior service line*
29. Additional Photo (if needed)
31. Additional Photo (if needed)

33. Responses will be required for every property.  If a response is not received, we will continue to contact you.  

    
    

35. Thank you for your cooperation!
Leave This Blank:


37. 1. Receive an email copy of this form.
38. Email address

    This field is not part of the form submission.

39. Submit

* indicates a required field