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Application For Construction Permit For Public Water System 327 IAC 8-3-3 35058 - Indiana
| Application For Construction Permit For Public Water System 327 IAC 8-3-3 Form. This is a Indiana form and can be used in Water Department Of Enviromental Management Statewide . |
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INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT INSTRUCTIONS FOR COMPLETING THE APPLICATION FOR CONSTRUCTION PERMITFOR PUBLIC WATER SYSTEM - 327 IAC 8-3-3 TYPE OR PRINT ALL ENTRIES The following numbers refer to the enclosed application. 1. 2. 3. 4. 5. 6. 7. 8. Enter the name of the Public Water System as they are chartered by the State of Indiana and check box if existing or new public water supply system. Enter the Public Water System Identification Number (PWSID) as chartered by the State of Indiana. Enter the name and title of the Public Water System official. Enter the telephone number of the Public Water System, including the area code. Enter the address of the Public Water System. Enter the fax number of the Public Water System. Enter the name of the project. Indicate the location of the project, which includes the city and reference to adjacent streets or roads. Example: "Bowling Green (city), Madison Street, one block east of Eel River, north side of S.R. 46" 9. 10. 11. Enter the county(s) where construction will take place. Indicate who is funding project. Enter the name, title and address of the person who is to receive the permit, generally the person representing the funding entity of the construction project (e.g., Developer, Superintendent, Utility Engineer) Note: In accordance with 327 IAC 8-3-2, the permit shall be issued in the name of the person who causes or allows construction, installation or modification of any facility, equipment, or device for any public water supply. 12. 13. 14. 15. 16. Enter the telephone number and fax, including area code, of the person who is to receive the permit. Enter the name of the local government official for Mayor, Town Board President, County Commissioner, if any. Enter the address of the local government officials. Enter the certification of the engineer. The engineer responsible for the design of the project will put his/her signature, the date and his/her seal [not just his/her Professional Engineer (P.E.) number] in the appropriate spaces. The engineer shall complete Attachment A, B, C, D and E, as appropriate. Note: The Engineer must be registered in the State of Indiana. 17. 18. 19. 20. 21. Print the name of the engineer. Enter the date signed and the P.E. seal. Enter the telephone number of the engineering firm, including the area code. Enter the fax number of the engineering firm. Enter the name and address of the firm mentioned in number 19, including street name and number, or Post Office box number, city, state and ZIP code. Over American LegalNet, Inc. www.FormsWorkflow.com 22. 23. 24. 25. 26. 27. 28. 29. Check box if project contains water main construction: Complete Attachment A. Check box if project contains well construction: Complete Attachment B. Check box if project contains pump construction: Complete Attachment C. Check box if project contains storage facility construction: Complete Attachment D. Check box if project contains chemical addition construction: Complete Attachment E. Check box if project contains treatment facility construction: Complete all applicable Attachments. Check appropriate boxes to questions concerning plans and specifications. Check 327 IAC 8-3-7(a) to see if a processing fee is necessary. If so, check the appropriate box(es) and enclose a check for the appropriate amount, made payable to: Indiana Department of Environmental Management. See example for address labels for a potentially affected person as defined by IC 4-21.5-3-5(b). If less than ten (10) potentially affected parties, you must provide mailing labels for each potentially affected person. Also, a Public Water System's official involved in this project should fill out the bottom section (No. 30) of the application. In addition, if ten (10) or more potentially affected parties, IDEM will publish a public notice through the local newspaper(s). As an option, you may indicate the name and address of the local newspaper(s) covering the area where the construction project will take place. 30. American LegalNet, Inc. www.FormsWorkflow.com APPLICATION FOR CONSTRUCTION PERMIT FOR PUBLIC WATER SYSTEM - 327 IAC 8-3-3 State Form 35058 (R6 / 9-04) FOR AGENCY USE Permit number WS - Approved by State Board of Accounts, 2004 Indiana Department of Environmental Management Drinking Water Branch 1. Name of Public Water System (PWS) New 3. Name and title of PWS official (i.e. Superintendent, Utility Engineer/Manager) 5. Address of PWS 7. Name of project 9. County(s) of project 10. Source of funding for the project 2. PWSID number Existing 4. Telephone number of PWS ((xxx) xxx-xxxx) 6. FAX number of PWS ((xxx) xxx-xxxx) 8. Location of project PWS Developer Dept. of Commerce (DOC) State Revolving Fund Other 12. Telephone number of person listed in item 11 ((xxx) xxx-xxxx). Fax number of item 11((xxx xxx-xxxx). 11. Name, title and address of the person who is to receive the permit, generally the person representing the funding entity of the cobnstruction project (e.g., Developer, Superintendent, Utility Engineer) 13. Name of local government official - Mayor 14. Address of Local Government Official - Mayor Town Board or Council President Address - Town Board or Council President County Commissioner (if any) Address - County Commissioner 15. Certification by Design Engineer I hereby certify that I am familiar with the information contained in this application and that to the best of my knowledge and belief, such information is true, complete and accurate. I further certify that construction of the proposed project following the application, plans and specifications will produce drinking water of satisfactory quality in accordance with 327 IAC 8. 16. Signature of engineer 17. Printed name of engineer 19. Telephone number of engineering firm 20. FAX number of engineering firm 18. P.E. seal 21. Name and address of engineering and developing firm, if applicable Date signed (month, day, year) FOR AGENCY USE Date received by IDEM (month, day, year) 23. For well construction: Complete Attachment B 24. For any pumping facility construction: Complete Attachment C 25. For storage facility construction: Complete Attachment D 26. For chemical addition: Complete Attachment E 27. For treatment facility construction: Complete all applicable Attachments 22. For water main construction: Complete Attachment A 28. Plans and Specifications A. Is one complete set of legible plans submitted? C. Is each and every page of the plans signed and sealed by a professi
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