Fillable TOWN OF SHREWSBURY NOTICE TO FACILITY OWNER & (SELCO)

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TOWN OF SHREWSBURY NOTICE TO FACILITY OWNER & (SELCO)

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Office of the TELEPHONE: (508) 841-8506
Dept. of Public Works watersewer@shrewsburyma.gov
TOWN OF SHREWSBURY
Richard D. Carney Municipal Office Building
100 Maple Avenue
Shrewsbury, Massachusetts 01545-5338
NOTICE TO FACILITY OWNER & INSTALLER
Each Backflow Device being installed requires a completed Backflow Prevention Device Design Data
Sheet (Prior to any Device Installations). This Data Sheet is available at the Plumbing Inspectors Office,
100 Maple Ave. Shrewsbury, Massachusetts 01545
You may also obtain this Data Sheet by visiting our website.
1. Go to www.shrewsburyma.gov/287/Water-Sewer-Division
2. Under Applications & Forms, select Cross-Connection Data Design Sheet
3. Fill out the application completely, attach the Required Drawing and email/fax to our
office for approval.
Important Installation Requirements:
To avoid having to remove and re-install any device, be sure that devices are installed in the following
manner by a Licensed Plumber.
1.Before installing any device, all pipelines shall be thoroughly flushed to remove foreign
matter.
2.Devices shall be located so as to permit easy access and provide adequate and convenient
space for maintenance, inspections, and testing.
3.Devices and shut-off valves must be installed in a horizontal alignment between 3 and 4
feet from the floor to the bottom of the device and a minimum of 12” from any wall.
4.Once we have approved your Device Design Data Sheet, you may install the device.
5.Once the device has been installed, you must schedule with our office for an inspection.
6.Refer to Mass DEP Cross Connection Control Regulations (310 CMR 22.22) for additional
information.
Thank You,
Richard Nolli
Cross Connection Inspector
Office: (508) 841-8601
Cell: (508) 523-0105
Fax: (508) 841-1567
Email: rnolli@shrewsburyma.gov
Cross-Connection/Backflow Preventer Device Design Data Sheet
(ALL FIELDS REQUIRED)
1. Owner’s Name:______________________________________________________________________
a) Address: ____________________________________________________________________
b) Phone No: ___________________________________________________________________
2. Facility Name: ______________________________________________________________________
a) Address: ____________________________________________________________________
b) Contact Person/ Agent: _________________________________________________________
c) Facility or Contact Phone #: _____________________________________________________
d) New Facility: ______________________Existing Facility: ____________________________
e) General Description of the Type of Business or Activity Conducted at this Facility:
______________________________________________________________________________
______________________________________________________________________________
3. Device Data:
a) Manufacturer:_______________________ Model #:______________ Serial#: _____________
b) RPBP: _____________________________ DCVA:__________________________________
c) Hot Water Device: ____________________ Cold Water Device:
________________________
d) Location of Device within the Premises: ___________________________________________
______________________________________________________________________________
e) By-Pass Arrangement: Yes:______________ No: ______________
f) Type of Shut-off Valve: ________________________________________________________
Page | 2
g) From What Type of Contamination is the Water Supply Protected:______________________
_____________________________________________________________________________
_____________________________________________________________________________
4. Piping Schematics Required:
a) A Fully Labeled, Detailed Schematic of the Potable and Non-potable Water Piping
immediately Surrounding the Backflow Prevention Device Installation showing the
Following:
i) Height above the Finish Floor to the bottom of the device. (Between 3 and 4 feet)
ii) Distance from Walls. (Minimum of 12”)
iii) Type of Equipment or System(s) Downstream of (after) the Backflow Prevention
Device. (Chemical Treatment, Operating Pressure, etc.)
iv) Manufacturer, Make, Model, Size and Alignment of the Backflow Prevention
Device.
v) Location of Upstream and Downstream Shut-off Valves.
****Device Testing Schedule & Fee****
****$75.00 per test, including a Retest when a Device Fails****
****Reduced Pressure Zone (RPZ) Twice per year by the SWD****
****Double Check Valve Assembly (DCVA) Once per year by the SWD****
**** Please Note that the piping schematic must be at least 8 ½” x 11” with a completed title block,
(Name of Facility, Address, Date, Preparer, Scale, etc.)****
**** Please utilize one Data Sheet for each Backflow Prevention Device installation submitted****
Submitted By: ________________________________________________________________________
Company: ___________________________________________________________________________
Address: ____________________________________________________________________________
Date: _______________________________________________________________________________
Phone#: _____________________________________________________________________________
Plumber’s Signature or
Sprinkler Fitter’s Signature: ______________________________________________________________
Plumber’s License # or
Sprinkler Fitter’s License #: ______________________________________________________________
Owner/Owners Agent Signature: __________________________________________________________
Page | 3
Reviewer’s Signature: ___________________________________________ Date: __________________
Submit to: Shrewsbury Water Dept.
Phone: (508) 841-8601 Cross Connection Office
Fax: (508) 841-1567
100 Maple Ave Shrewsbury, Ma 01545
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TOWN OF SHREWSBURY NOTICE TO FACILITY OWNER & (SELCO)

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Completed 5 August 2020

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