Application For Construction Permit For Public Water System 327 IAC 8-3-3 {35058}

INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT INSTRUCTIONS FOR COMPLETING THE APPLICATION FOR CONSTRUCTION PERMIT FOR PUBLIC WATER SYSTEM - 327 IAC 8-3-3 TYPE OR PRINT ALL ENTRIES. The following numbers refer to the enclosed application. 1. 2. 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. Enter the email address of the PWS Official listed in item 3. NOTE: A valid email address is requested because the issued permit will be emailed to expedite delivery. Enter the county(s) where construction will take place. 3. 4. 5. 6. 7. 8. 9. 10. 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, along State Road 46" 11. Check the appropriate box(s) indicating who is funding this project. 12-14. Enter the name, mailing address and email address of the local government official applicable to the project. Complete box 12 with Mayor's information or complete box 13 with Town Board President's or Council information. Or if project is within county government purview, complete box 14 with County Commissioner's information. 15. The professional engineer, licensed professional geologist, or licensed well driller must check the box indicating they agree to the certification statement listed. All plans, specifications and applications must be prepared by or under the direct supervision of a professional engineer registered in Indiana, except when 327 IAC 8-3-2.1 applies. For small transient (serving 250 or fewer individuals per day) and small non-transient (serving 100 or fewer individuals per day) public water systems not utilizing surface water or ground water under the direct influence of surface water at its source and are not a county, city, town, township, a school corporation or any other political subdivision, the application, plans and specifications may be certified by a professional engineer, licensed well driller or a license professional geologist. If not for sure, submit your question to the Permits Section via email at dwpermits@idem.in.gov or by calling (317) 234-7425. 16. The professional engineer, licensed professional geologist, or licensed well driller responsible for the design of the project will put his/her seal and/or license number in this box. This person shall complete Attachment's A, B, C, D and E, as applicable. 17. Signature and printed name of the professional engineer, licensed professional geologist, or licensed well driller certifying the application, plans and specifications. 18. Enter email address of the professional engineer, licensed professional geologist, or licensed well driller certifying the application, plans and specifications. NOTE: A valid email address is requested because the issued permit will be emailed to expedite delivery. 19. Enter telephone number for the person in Box 17. Over American LegalNet, Inc. www.FormsWorkFlow.com  20. Fax number for the person in Box 17. 21. Name and address of the business the person from Box 17 is affiliated with, if applicable. 22. If project contains water main construction, check box and complete Attachment A. 23. If project contains well construction, check box and complete Attachment B. 24. If project contains pump construction, check box and complete Attachment C. 25. If project contains storage facility construction, check box and complete Attachment D. 26. If project contains chemical addition construction, check box and complete Attachment E. 27. If project contains treatment facility construction, check box and complete all applicable Attachments. 28. Check appropriate boxes to questions concerning plans and specifications. NOTE: You may submit the completed application, specifications and drawings digitally at dwpermits@idem.in.gov. Electronic documents must be legible and in PDF format. The drawings and the cover page of the specifications must contain certifier's signature and seal if applicable. If a construction permit processing fee is required, follow the instructions provided at number 29. 29. Check 327 IAC 8-3-7(a) to see if a processing fee is required. Exempt organizations are both a governmental entity and one of the listed categories. If you are not a governmental entity, then you are not exempt from the construction permit processing fee. If not sure, contact the Permits Section via email at dwpermits@idem.in.gov or by calling (317) 234-7425, prior to submitting the permit application. If a processing fee is required, check the appropriate box(es) and submit payment using one (1) of the following options: A. Make check/money order payable to IDEM (Acct.#3240-414000-140000) and mail with a copy of the completed first page of the permit application to: IDEM PO Box 3295 Indianapolis, IN 46206-3295 B. Remit by ACH to: ABA#: 071921891 Bank Account Number: 4620695315 Bank Account Name: State of Indiana AND send a copy of the first page of the completed permit application, amount of payment and payment date to water@idem.in.gov. C. To pay by credit card, call (317) 234-3099 and leave the information requested in the telephone message and email copy of the first page of the completed permit application, the amount of payment and payment date to water@idem.in.gov. Public Notification: IDEM typically provides a thirty (30) day public comment period on all drinking water projects requiring an individual construction permit. Public notice is provided on IDEM's Public Notice website, which is located at: http://www.in.gov/idem/5474.htm. The notice includes information on the project, as well as where to obtain the proposed permit and related documents, and how to submit comments. The permit is effective immediately upon issuance after the public notice period has ended. Notice of Decision: Another option for public notice is written notification (Notice of Decision) of issuance of the construction permit to potentially affected parties, as defined by IC 4-21.5-3-7. For this option, a complete list of potentially af