NOTICE OF INTENT TO CONSTRUCT A WATER MAIN EXTENSION State Form 49008 (R / 10-04) Approved by State Board of Accounts, 1998 General Construction Permit For Water Main Extensions 1. Title of proposed project 2. County of proposed project 3. Location of proposed project (including nearest public intersection and nearest quarter Section, Township, Range) 4. Name, title, and firm of responsible person ( as defined in 327 IAC 8-3.5-6) 5. Telephone number of responsible person 6. Address of responsible person 7. Name of Public Water System (PWS) 8. PWS ID Number 9. Address of PWS 10. Telephone number of PWS 11. Name and firm of professional engineer 12. Telephone number of professional engineer 13. Address of professional engineer 14. Name of developer 15. Telephone number of developer 16. Address of developer 17. Timing of construction (check one of the following): The proposed construction of the water main will begin on and be completed . (Cannot begin construction less than thirty (30) days after IDEM receives a complete and sufficient NOI.) on The proposed construction schedule will be submitted separate from this NOI at least ten (10) working days before the commencement of the construction and will include a copy of the information on the first page of this NOI. (Cannot begin construction less than thirty (30) days after IDEM receives a complete and sufficient NOI.) 18. Fee Schedule: THE COMPLETE NOTICE OF INTENT ALONG WITH ALL REQUIRED FEES MUST BE SUBMITTED BY CERTIFIED MAIL TO: No fee, exempted under 327 IAC 8-3-7(a). $250 for water main extensions from 5001 to 10,000 linear feet. DRINKING WATER BRANCH Indiana Department of Environmental Management 100 North Senate Avenue Indianapolis, Indiana 46204 $500 for water main extensions greater than 10,000 linear feet. Make checks payable to: I.D.E.M. (Acct.# 3240-414000-140000). No fee for water main extensions under 2,500 linear feet. $150 for water main extensions from 2,501 to 5,000 linear feet. 19. Certifications: Responsible Person: "I certify that I have reviewed and understand the applicability and eligibility requirements of this rule and that the water main proposed with the submission of this NOI meets the applicability and eligibility requirements of this rule. I also certify that the design and construction of this project will be performed under my direction or supervision to assure conformance with 327 IAC 8-3.5 and will meet all local rules or laws, regulations and ordinances. The information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment. Date signed (month, day, year) Signature of responsible person Professional Engineer: "I certify under the penalty of law that the design of this project will be performed under my direction or supervision to assure conformance with 327 IAC 8-3.5 and that the plans and specification will require the construction of said project to be performed in conformance with this rule. The design of the proposed project will meet all local rules or law, regulations and ordinances. The information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment." Date signed (month, day, year) Signature of professional engineer (Continued on Page 2.) Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com NOTICE OF INTENT TO CONSTRUCT A WATER MAIN EXTENSION 10-04 Indiana Department of Environmental Management Office of Water Quality State Form 49008 (R / 10-04) Developer: "I certify under the penalty of law that the construction of this project will be performed under my direction or supervision to assure conformance with 327 IAC 8-3.5. The construction of proposed project will meet all local rules or laws, regulations and ordinances. The information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment." Date signed (month, day, year) Signature of developer: PWS Representative: "I certify under the penalty of law that I have agreed to furnish water to the area in which the water main is proposed. I acknowledge the public water system's responsibility for examining the plans and specifications to determine that the proposed water main meet local rules or laws and ordinances. I also acknowledge the public water system's responsibilities as outlined in 8-3.5-12. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment." Date signed (month, day, year) Signature of PWS representative: 20. Project Design Criteria: Alternative Technical Standards (327 IAC 8-3.2.20) 21. Are any "Alternative Technical Standards" proposed to be used in this project? Yes, I have attached copies of the approval with the NOI. No Public Water System Capacity Status B. GPM 24. Average of five Peak Daily Demand (PDD) listed above: C. MGD 25. Ratio of PDD to PWS Daily Production Capacity = (Item D = Item C / Item A x 100) D. % 22. The PWS's Daily Production Firm Capacity: MGD A. 23. The PWS's five (5) highest demand days in the previous two (2) years: Demand (MGD) Date 1. 2. 3. 4. 5. 26. Anticipated Customer Demand of Proposed Water Main Residential Customers: E. Number of homes F. Average Daily Demand times Peaking Factor (at least 0.87 gpm/home) Total Average Daily Demand times Peaking Factor (G = E x F) G. gpm Other (Commercial and Industrial) Customers: Average Daily Demand ( the "Safe Maximum Operating Capacity" of domestic meter) Description (including size of domestic meter): gpm gpm Sub Total: H. gpm Total Customer Demand of Proposed Water Main (gpm) = (Item G + item H) I. gpm 27. Ratio of total Customer Demand of Proposed Water Main (gpm) to the PWS Daily Production Firm Capacity (gpm) (Item J = Item I/ Item B x 100) J. % Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com