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Application For Construction Permit For Public Water System 327 IAC 8-3-3 Form. This is a Indiana form and can be use in Department Of Enviromental Management Statewide.
Tags: Application For Construction Permit For Public Water System 327 IAC 8-3-3, 35058, Indiana Statewide, Department Of Enviromental Management
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. 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. 3. Enter the name and title of the Public Water System official. 4. Enter the telephone number of the Public Water System, including the area code. 5. Enter the address of the Public Water System. 6. Enter the fax number of the Public Water System. 7. Enter the name of the project. 8. 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. Enter the county(s) where construction will take place. 10. Indicate who is funding project. 11. 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. Enter the telephone number and fax, including area code, of the person who is to receive the permit. 13. Enter the name of the local government official for Mayor, Town Board President, County Commissioner, if any. 14. Enter the address of the local government officials. 15. Enter the certification of the engineer. 16. 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. Print the name of the engineer. 18. Enter the date signed and the P.E. seal. 19. Enter the telephone number of the engineering firm, including the area code. 20. Enter the fax number of the engineering firm. 21. 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. Check box if project contains water main construction: Complete Attachment A. 23. Check box if project contains well construction: Complete Attachment B. 24. Check box if project contains pump construction: Complete Attachment C. 25. Check box if project contains storage facility construction: Complete Attachment D. 26. Check box if project contains chemical addition construction: Complete Attachment E. 27. Check box if project contains treatment facility construction: Complete all applicable Attachments. 28. Check appropriate boxes to questions concerning plans and specifications. 29. 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. 30. 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. American LegalNet, Inc. www.FormsWorkflow.com APPLICATION FOR CONSTRUCTION PERMIT FOR PUBLIC WATER SYSTEM - 327 IAC 8-3-3 Permit number State Form 35058 (R6 / 9-04) WS - FOR AGENCY USE Approved by State Board of Accounts, 2004 Indiana Department of Environmental Management Drinking Water Branch 1. Name of Public Water System (PWS) 2. PWSID number New Existing 3. Name and title of PWS official (i.e. Superintendent, Utility Engineer/Manager) 4. Telephone number of PWS ((xxx) xxx-xxxx) 5. Address of PWS 6. FAX number of PWS ((xxx) xxx-xxxx) 7. Name of project 8. Location of project 9. County(s) of project 10. Source of funding for the project PWS Developer Dept. of Commerce (DOC) State Revolving Fund 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) Other 12. Telephone number of person listed in item 11 ((xxx) xxx-xxxx). Fax number of item 11((xxx xxx-xxxx). 13. Name of local government official - Mayor Town Board or Council President County Commissioner (if any) 14. Address of Local Government Official - Mayor Address - Town Board or Council President 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. 18. P.E. seal 16. Signature of engineer 17. Printed name of engineer 19. Telephone number of engineering firm 20. FAX number of engineering firm 21. Name and address of engineering and developing firm, if applicable Date signed (month, day, year) FOR AGENCY USE 22. For water main construction: Complete Attachment A 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 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 professional engineer? Yes No B. Is a set of specifications submitted with the cover page signed and sealed by P.E.? Yes No On IDEM file D. Is a plan no more than 1 year old showing the sizes and locations of all mains in the distribution system available? (If Yes, submit a copy) Yes No Page 1 Yes No American LegalNet, Inc. www.FormsWorkflow.com 29. Construction Permit Processing Fee Schedule NOTE: THIS APPLICATION WILL BE RETURNED IF NOT ACCOMPANIED WITH THE REQUIRED FEE UNLESS THE APPLICANT IS AN EXEMPTED GOVERNMENT ENTITY, WHICH INCLUDES A COUNTY, MUNICIPALITY, OR TOWNSHIP WHICH IS DEFINED AS A UNIT UNDER IC 36-1-2-23, A NONPROFIT ORGANIZATION , A CONSERVANCY DISTRICT, A SCHOOL CORPORATION, OR REGIONAL WATER OR SEWAGE DISTRICT [327 IAC 8-3-7(a)]. A. New public water system treatment plant Groundwater: Up to 500,000 gallons per day Greater than 500,000 gallons per day Surface water: Up to 500,000 gallons per day Greater than 500,000 gallons per day C. Other water treatment facilities Wells Pump or pump station Chemical addition Storage tank $ 875 $ 1,750 $ 1,250 $ 2,500 $ 500 $ 100 $ 250 $ 200 Miscellaneous process modification $ 50 per process B. Public water system treatment plant expansion Up to fifty percent (50%) design capacity D. All water distribution system Up to 500,000 gallons per day $ 625 Greater than 500,000 gallons per day $ 1,250 Greater than fifty percent (50%) design capacity Up to 2,500 linear feet 2,501 - 5,000 linear feet $ 150 5,001 - 10, 000 linear feet $ 250 Greater than 10,000 linear feet Up to 500,000 gallons per day $ 1,250 Greater than 500,000 gallons per day $ 2,500 $ 0 $ 500 THE COMPLETED APPLICATION, ALONG WITH ALL REQUIRED FEES AND ATTACHMENTS SHOULD BE MAILED TO: Drinking Water Branch Indiana Department of Environmental Management 100 N. Senate Ave. Indianapolis, Indiana 46204 Make checks payable to: Indiana Department of Environmental Management (Account # 3240-414000-140000) 30. Identification of potentially affected persons The Administrative Orders and Procedures Act requires that the Department of Environmental Management (DEM) give notice of its decision on your application to POTENTIALLY AFFECTED PERSONS AS DEFINED BY IC 4-21.5-3-5(b) including: a. each person to whom the decision is specifically directed; b. each person to whom a law requires notice to be given; c. each competitor who has applied to the DEM for a mutually exclusive license, if issuance is the subject of the decision and the competitor's application has not been denied in an order for which all rights to judicial review has been waived or exhausted; d. each person who has provided the DEM with a written request for notification of the decision; e. each person who has substantial and direct proprietary interest in the issuance of the permit / variance; f. each person whose absence as a part in the proceedings concerning the permit / variance decision would deny an- other party complete relief in the proceeding or who claims an interest related to the issuance of the permit / variance and is so situated that the disposition of the matter in the person's absence may; 1 . as a practical matter impair or impede the persons ability to protect that interest, or 2. leave any other person who is a party to a proceeding concerning the permit subject to a substantial risk of incurring multiple or otherwise inconsistent obligations by reason of the person's claimed interest. IC 4-21.5-3-5(f) provides that we may request that you assist us in identifying these people. Our failure to properly identify and notify these people of the decision could result in voiding the decision which is made. List below persons whom you have reason to believe have a substantial or proprietary interest in this matter, or could otherwise be considered to be potentially affected under the law. Failure to notify a person who is later determined to be potentially affected could result in voiding our decision on procedural grounds. To ensure conformance with the Administrative Orders and Procedures Act and to avoid reversal of a decision, you must list all such parties and must provide mailing labels for all potentially affected parties. The labels shall read as follows: Name of affected party, Address (number and street or rural route number), City, State and ZIP code. (Optional) If ten (10) or more potentially affected parties, please indicate name and address of local newspaper(s) covering where the construction will take place: Name of local newspaper(s) Address of local newspaper(s) (number and street) City, state, ZIP code I certify, that to the best of my knowledge, I have listed all the potentially affected parties, as defined by IC 4-21.5-3-5(b), known to me and provided mailing labels. If "NONE" is indicated it signifies that no such parties exist. Official signature of Public Water System Date signed (month, day, year) Printed name and title of official Page 2 American LegalNet, Inc. www.FormsWorkflow.com APPLICATION FOR CONSTRUCTION PERMIT FOR PUBLIC WATER SYSTEM - 327 IAC 8-3-3 Attachment A Water Main Construction State Form 35058 (R6 / 9-04) Approved by State Board of Accounts, 2004 Indiana Department of Environmental Management Drinking Water Branch 1. Water Main Construction A. This construction is (check all that apply) New Replacement Relocation B. Water Main Description Diameter Material Type Length Class Pressure Rating Types of Joints Total Length = C. Depth of cover per frost penetration table under IAC 8-3.2-17(d) D. Is the proposed main providing fire protection? inches Yes E. Will the main be pressure/leak tested per American Water Works Association (AWWA) C600-99? If No, please attach a detailed description of the pressure/leak testing method. F. Will the main be disinfected per AWWA, C651-99? Yes Yes No No No If No, please attach a detailed description of the disinfection method. G. Will fire hydrants and water mains at each tee, bend, and dead end be blocked or anchored per AWWA, C600-99? If No, please attach a detailed description of the method. Yes No 2. Design Specifics and Plans A. Minimum horizontal clearance between water mains and sewers (including storm drains) shall be 10 feet (ref. 327 IAC 8-3.2-9). Yes No C. Are there any stream crossings? B. Minimum vertical clearance between water mains and sewers (including storm drain) shall be 18 inches (ref. 327 IAC 8-3.2-9) Yes No D. What is the maximum spacing between valves? E. What is the maximum spacing between hydrants? Yes No F. Is there a history of external corrosion problems with buried pipe in the project area? If Yes, provide copy of any corrosion study and explain corrosion protection measures. Yes No 3. System Design Data A. System's total plant capacity: (Not firm capacity) B. Number of existing service connections served by C. Number of service connections to be served by the proposed water main extension Public Water System GPD D. Demand of Water Main Extension 1. Fire Flow gpm 2. Unit Peak Daily Demand (per new customer) gpm 3. Total Peak Daily Demand with Fire Flow of new water main extension [(Unit Peak Daily Demand x number of customers) + fire flow] gpm E. Pressure at the "Total Peak Daily Demand, No Fire Flow" flow rate at the point of connection psi F. Pressure at the "Total Peak Daily Demand with Fire Flow" flow rate at the point of connection psi Page 1 Over American LegalNet, Inc. www.FormsWorkflow.com I. The Public Water System's five (5) highest demand days in previous two (2) years. Date Demand (GPD) 1. 2. 3. 4. 5. 2 year Average Daily Demand (average of 1 through 5 above) GPD 4. Summary of Flow Test Data (data must be attached) 1. Date of flow test 2. Static pressure at flow test location psi 3. Flow test flow rate gpm 4. Residual pressure at flow test flow rate psi SKETCH THE FOLLOWING: Show the relationship between fire flow test location and the point of connection of proposed water main. Include all water main piping information including lengths, diameters and material type. Include the elevations at both fire flow location and point of connection. Show north arrow. No scale is necessary if pipe lengths are noted. 5. This flow test was taken at: Fire Hydrants (wide open) Fire Hydrants (open to sustain 20 psi residual pressure) Flushing Hydrants (wide open) Tank level during test Booster pump within the pressure zone of the proposed water main On Off 5. Water Main Extension Hydraulic Calculation Enclosed Hydraulic Model or Enclosed Hydraulic Calculations 6. Alternative Technical Standard (check all that apply) This application cites pre-approved alternative technical standards (copy attached). This application proposes alternative technical standards (attached demonstration per 327 IAC 8-3.2-20) No alternative technical standards are utilized in this project. Page 2 American LegalNet, Inc. www.FormsWorkflow.com 7. Certification to Furnish Water (this section must be completed) The has agreed to furnish City, Town, Village, Water Company or Water Authority water to the area in which water main extensions are proposed by Name the person representing the funding entity of the construction project (e.g., developer) according to plans titled " " and prepared by . The undersigned acknowledges the public Name of Engineering Firm water supplier's responsibility for examining the plans and specifications to determine that the proposed extensions meet local rules or laws, regulations and ordinances. Date signed (month, day, year) By: (signature of Public Water System official) Name of Public Water System Title Page 3 American LegalNet, Inc. www.FormsWorkflow.com APPLICATION FOR CONSTRUCTION PERMIT FOR PUBLIC WATER SYSTEM - 327 IAC 8-3-3 Attachment B Well Construction State Form 35058 (R6 / 9-04) Approved by State Board of Accounts, 2004 Indiana Department of Environmental Management Drinking Water Branch NOTE: Before review of your well construction permit application can begin, two (2) copies of the following must be provided : A. B. C. D. A well-site approval Copies of recorded deeds or easements showing control of the land immediately surrounding the well head Data showing 100 years or highest known flood elevations in the area Well design specifications (Attachment B Well Construction) 1. Well Design Specifications A. How many existing wells are in the well field? B. What is the rated capacity of each existing well if the proposed well is in an existing well field? C. How many new wells are intended? D. What type of well is proposed? (gravel pack, tubular, radial collector, etc.) E. What is the estimated depth of the well? F. Length of casing Casing material Diameter of casing Elevation of the top of the casing G. If the well will be in a pumphouse, how far will the well casing extend above H. If applicable, how far does the casing extend into the pump base? the pump house floor? I. How far above final ground surface will the well casing extend? J. Length of screen Diameter of screen Material and slot size of screen K. If applicable, what type of grouting material will be used? L. To what depth will the well be grouted? M. What type of well pump is intended? (line shaft, submersible, etc.) (attach pump curves) N. What is the pump's rated capacity and total dynamic head (TDH) of each proposed pump? Anticipated system demand Designed entrance velocity of screen O. What type of pump lubrication will be used? GPM P. What type of provision is made for periodic water level measurements in the well? Q. Will the discharge piping be equipped with the following: Yes No Check valve Yes No Presure guage Yes No Smooth-nosed sampling tap Yes No Shut-off valve Yes No Means of measuring flow Yes No Air release/vacuum relief valve Yes No R. Do the specifications describe the test pumping procedures? (if not, please explain) S. How will power be supplied to the pumps in the event of an interruption to the primary power source? T. Is this proposed well(s) included in well head protection plan development? Yes No American LegalNet, Inc. www.FormsWorkflow.com APPLICATION FOR CONSTRUCTION PERMIT FOR PUBLIC WATER SYSTEM - 327 IAC 8-3-3 Attachment C Pumping Station State Form 35058 (R6 / 9-04) Approved by State Board of Accounts, 2004 Indiana Department of Environmental Management Drinking Water Branch A. What is the 100 year or highest known flood elevation in the area? B. What is the pumphouse floor elevation? C. What is the elevation of the finished grade at the D. How many pumps are provided? (attach pump pumphouse location? curves) E. What peak demand (gpm) is the pump(s) designed for? F. What is the rated capacity (gpm) of each proposed pump and total dynamic head (TDH)? G. How will power be supplied to the pumps in the event of an interruption to the primary power source? H. What kind of monitoring will be provided and what is the form of communication? I. Does each pump have a pressure gauge on its discharge line and a compound gauge on its suction line? Yes No J. Is there a low suction cut-off control? Yes If Yes, what is its setting? No K. How is the total discharge of the pump(s) measured? L. Does the pump have a check valve? Yes If Yes, where is the check valve located? No American LegalNet, Inc. www.FormsWorkflow.com APPLICATION FOR CONSTRUCTION PERMIT FOR PUBLIC WATER SYSTEM - 327 IAC 8-3-3 Attachment D Storage Facilities State Form 35058 (R6 / 9-04) Approved by State Board of Accounts, 2004 Indiana Department of Environmental Management Drinking Water Branch A. What is the 100 year or highest known flood elevation in the area? B. What type of storage facility is proposed? (standpipe, elevated, ground, etc.) C. What is the capacity of the storage facility? D. What is the elevation at the base of the storage facility? E. What is the purpose of the water storage facility? a. Volume b. Pressure F. Are there other existing water storage tanks within the system? c. Fire protection G. What is the size (gallons) of the existing tank(s) and overflow elevation? Yes No H. What is the average daily consumption of the system? I. How is the storage facility isolated from the distribution system? J. What is the filling rate of the storage facility? K. What size is the overflow pipe? What size screen? Is the overflow pipe screened? Yes No L. What is expected to be the operating head range of the storage facility? M. What provisions have been made to monitor water levels in the storage facility? N. What provisions have been made to allow for draining of the storage facility? O. Where are the sampling taps located? P. How is the storage facility protected from trespassers, vandalism and sabotage? Site fenced Yes No Alarm Yes No Ladder guard Yes No Lighting Yes No Hatch locked Yes No Q. Is cathodic protection being used? R. How is the storage facility being protected from freezing? American LegalNet, Inc. www.FormsWorkflow.com APPLICATION FOR CONSTRUCTION PERMIT FOR PUBLIC WATER SYSTEM - 327 IAC 8-3-3 Attachment E Chemical Addition State Form 35058 (R6 / 9-04) Approved by State Board of Accounts, 2004 Indiana Department of Environmental Management Drinking Water Branch A. What is the common / brand name of the intended chemical? What is the chemical name of the intended chemical? B. Does the chemical have the approval of any of the following: Yes No National Sanitation Foundation (NSF) Yes No Underwriters Laboratory (UL) Yes No Food and Drug Administration (FDA) C. What is the purpose of the chemical addition? D. Technical data supplied on the chemical (check all that apply) Material Safety Data Sheet Manufacturer's Label Toxicology Data Other Studies / Literature Case Histories of Chemical Use E. Describe or provide technical information on the type of proposed feed equipment F. Describe or provide technical information on the type of proposed feed controls G. What is maximum and minimum feed range? H. How have chemical feed rates been determined? (attach supporting documentation) I. Is there a means of measuring the quantity of chemical used? Yes No J. Do the plans show the following? Location of all feeders Yes No K. What type of cross connection control is provided? All points of chemical application L. Are there leak detectors provided? Yes No Piping layout Yes No Yes No Are there spill containments provided? Yes No American LegalNet, Inc. www.FormsWorkflow.com