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BACKFLOW PERMIT APPLICATION
Name of Project
Address of Project
General Contractor
Foreman
Contractor Address
Phone      Fax
Plumber
Utility Contractor
License
Phone     Fax
Plumber Address
How many backflow
assemblies are planned
for this project?
Notes

Backflow Assembly Information

Containment at Meter Containment at Meter
Isolation at Cross Connection Isolation at Cross Connection
Fire Service Fire Service
Irrigation Service Irrigation Service
Manufacturer Manufacturer 
Model   Model 
Size   S/N Size   S/N
Location on site Location on site

Containment at Meter
Isolation at Cross Connection
Fire Service
Irrigation Service
Manufacturer 
Model  
Size S/N
Location on site

I have read the backflow assembly installation requirements below and
will abide by said requirements.

Date

Printed Name of Plumber/Contractor




Backflow Assembly Installation Guide

  • The backflow assembly should be as close to the water meter
    as possible. In all cases it shall be before the first branch in the
    water service. Call the City for more information about isolation
    backflow assemblies.
  • The double check valve and reduced pressure assemblies shall
    be installed at least 12 inches above the finish grade, flood level
    or floor.
  • Pressure vacuum breaker assemblies (PVB) shall be installed at
    least 12 inches above the highest water outlet. When installing a
    PVB on an irrigation system consider the placement of sprinkler
    heads on hills and slopes. PVB shall not be installed at a lower
    level than the highest outlet.
  • The maximum installation height of a backflow assembly is sixty
    inches.
  • An enclosure shall be provided that protects the assembly from
    theft, vandalism, tampering, weather, and frost.
  • In the floor, underground and vault installations are prohibited.
  • There shall be 24 inches clearance on all sides of the assembly.
  • Electrical equipment, outlets and breaker boxes shall not be
    located beneath the assembly.
  • Only in-line testable assemblies approved by the USC Foundation
    for Cross Connection Control or ASSE shall be accepted.
  • The type of assembly shall be appropriate for the hazard as
    identified by the Cross Connection Control Office.
  • Prior to installing assemblies it is recommended that the Cross
    Connection Control Office be contacted to verify that the type of
    assembly being used is appropriate for the hazards.
  • Installation, relocation, or replacement of backflow prevention
    assemblies requires a City of Wilmington permit and inspection
    and a separate New Hanover County plumbing permit and inspection.
    Water meters will not be set until the City has inspected and approved
    the backflow assembly and its installation.
  • Backflow assemblies shall be tested by a certified tester within
    30 days of the installation and annually thereafter.

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Post Office Box 1810    Wilmington, NC 28402-1810


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