INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM PUBLIC WATER SUPPLY PERMIT APPLICATION PACKAGE Included in this package is a NPDES Public Water Supply Permit Application Form, an Instruction Sheet, a Fee Information Sheet and a Potentially Affected Persons Form. Please complete all requested information and return it to the address indicated on the Application Form. PUBLIC WATER SUPPLY APPLICATION COMPLETENESS CHECKLIST The following information must be included as part of the NPDES permit application: Completed, signed and dated Application Form Fifty dollar ($50) Permit Application Fee Potentially Affected Persons List Topographic map indicating outfall location(s) American LegalNet, Inc. www.FormsWorkflow.com PUBLIC WATER SUPPLY NPDES PERMIT APPLICATION INSTRUCTION SHEET 1. Name of Authorized Public Water Supply Official: Enter the name of the Mayor, Director of Utilities, Plant Superintendent, ranking elected official or other legally responsible person. 2. Name of Public Water Supply: Give the facility's official or legal name. 3. Mailing Address: Give the complete mailing address of the office where correspondence should be sent. 4. Name of Primary Contact Person: Enter the name of a person who is familiar with the operation of the facility and with the facts reported in this application and who can be contacted by the IDEM if necessary. 5. Phone Number: Give the phone number of the office where the contact person may be reached. 6. E-mail Address: Give the e-mail address of the contact person (Optional). 7. Facility Address: Give the address or location of the facility. If the facility lacks a street name or route number, give the most accurate alternative geographic information (e.g., section number or quarter section number from county records or at intersection of Rts. 425 and 22). 8. Phone Number: Give the phone number of the facility. 9. E-mail Address: Provide an e-mail address through which the facility can be contacted (Optional). 10. Permit Status: Indicate whether the application is for a new facility, or for the renewal of an existing permit. If the application is for a permit renewal, indicate whether a modification to the existing permit is requested. 11. NPDES Permit Number: Provide the NPDES Permit Number of the source (if a permit renewal or modification). 12. Identification and Location of Outfalls: Identify each discharge point by outfall number (e.g., Outfall 001, Outfall 002) and give the name of the stream receiving the facility's discharge. If the receiving stream is an unnamed ditch, swale or field tile, then also list the first named water body into which the receiving stream flows. Also identify the County and the latitude and longitude (or U.S. Geological Survey Quadrangle name, section, range, and township) where the discharge enters the receiving stream. Include a topographic map with each outfall clearly marked. Use a supplemental sheet to list additional outfall(s). 13. Source of Intake Water: Indicate the source of the treated water for each outfall identified in #12. 14. Source of Wastewater: Indicate those components that contribute to the discharge of wastewater to surface waters. Do not list chemicals or treatment that are added or occur which are not discharged with the wastewater. 15. Other Chemical Treatments: List all other chemical treatments that may be discharged. 16. Contaminants in Intake Water: Indicate if you have any reason to believe pesticides or other contaminants are present in the intake water. In the space provided, please list the contaminants that you believe are present in the intake water. 17. Treatment: Give a brief narrative description of any treatment that the backwash water undergoes prior to its discharge (i.e. sedimentation). 18. Volume of Discharge: Give the average and maximum flow of the daily discharge in gallons per day. If the application is for a new facility, give an estimate of the volume of discharge. 19. Signature: The application form must be signed by a person legally responsible for the facility. American LegalNet, Inc. www.FormsWorkflow.com National Pollutant Discharge Elimination System: PUBLIC WATER SUPPLY PERMIT APPLICATION Indiana Dept. of Environmental Management Office of Water Quality - NPDES Permits Section 100 N. Senate Avenue Indianapolis, IN 46204 Phone: (317) 232-8603 or 1-800-451-6027 (Indiana Residents Only) http://www.in.gov/idem/water/permits/applications.html State Form 50103 (R / 10-04) Form Approved by State Board of Accounts, 2004 INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT NOTE: This form is part of a NPDES public water supply permit application package; the following must be included as part of the NPDES permit application: - A completed, signed, dated application form (this form), - $50 permit application fee, - potentially affected persons list, - and a topographic map indicating outfall location(s). PART A: GENERAL INFORMATION 1. Name of authorized public water supply official: 2. Name of public water supply: 3. Mailing address: State: City: ZIP Code: CONTACT PERSON 4. Name of primary contact person: 5. Phone number ((xxx)) xxx-xxxx: 6. E-mail address (optional): FACILITY 7. Facility address: State: City County: ZIP Code: 9. E-mail address (optional): 8. Phone number ((xxx)) xxx-xxxx: PERMIT APPLICATION STATUS 10. Permit type (check one): New Renewal Modification 11. NPDES Permit Number (if facility has an existing permit): PART B: FACILITY INFORMATION 12. Identification and location of outfalls (include a topographic map showing location of outfall(s)): a. Outfall No.- Latitude: Longitude: Receiving stream: b. Outfall No.- County: Latitude: Longitude: Receiving stream: County: 13. Source of intake water (check each source for each outfall identified in #12): Outfall No. a. Outfall No.b. Outfall No.- Source Well Surface stream Lake Well Surface stream Lake (Continued on page 2) Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com PART B: FACILITY INFORMATION (continued) 14. Source of wastewater (check all that apply) # Source of wastewater a. b. Zeolite Softener Waste c. Outfall No.- Filter Backwash Lime Softener Waste d. Floor Drains e. Outfall No.- Sedimentation Basin Waste f. Carbon Filtration g. Total Residual Chlorine h. Flocculent(s) Used ? Type of Flocculent(s): 15. List all other chemical treatments used that may be discharged: 16. Do you have any reason to believe pesticides or other contaminants are present in the intake water? a. Pesticides: Yes No b. Other contaminants: Yes No Please list: 17. Treatment (of backwash water): 18. Volume of Discharge (gallons/day): a. Average: b. Maximum PART C: SIGNATURE BLOCK 19. Signature: This application must be signed by a person in responsible charge to be valid. This signature attests to the following: "I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, 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 for knowing violations". (Printed Name) (Title) (Signature) (Date Signed) (mm/dd/year) Return Completed Application and Associated Materials to: Indiana Department of Environmental Management Office of Water Quality - NPDES Permits Section 100 North Senate Avenue Indianapolis, Indiana 46204 Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com OWQ Form: Affected TO: Applicant FROM: Indiana Department of Environmental Management Office of Water Quality Permits Section SUBJECT: Revised 10-04 Identification of Potentially Affected Persons The Administrative Orders and Procedures Act (AOPA) IC 4-21.5, requires that the Department of Environmental Management (IDEM) give notice of its decision on your application to the following persons: (a) each person to whom the decision is specifically directed; (b) each person to whom a law requires notice be given; (c) each competitor who has applied to the IDEM 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 have been waived or exhausted; (d) each person who has provided the IDEM with a written request for notification of the decision; (e) each person who has a substantial and direct proprietary interest in the issuance the (permit) (variance); (f) each person whose absence as a party in the proceeding concerning the (permit) (variance) decision would deny another 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 person's 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 claim interest. IC 4-21.5-3-5(f) provided that we may request your assistance in identifying these people. Our failure to properly identify and notify these people of the decision could have the result of voiding any decision which is made. Additionally, IC 13-15-3-1 requires IDEM to send notice that the permit application has been received by the department to the following: (a) the board of county commissioners of a county affected by the permit application and (b) the mayor of a city that is affected by the permit application, or (c) the president of a town council of a town affected by the permit application. Please provide on the attached form the names of those persons affected by these statutes. American LegalNet, Inc. www.FormsWorkflow.com IDENTIFICATION OF POTENTIALLY AFFECTED PERSONS State Form 50103 (R / 10-04) Form Approved by State Board of Accounts, 2004 INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT NOTE: This form is part of a NPDES public water supply permit application package; the following must be included as part of the NPDES permit application: Indiana Dept. of Environmental Management Office of Water Quality - NPDES Permits Section 100 N. Senate Avenue Indianapolis, IN 46204 Phone: (317) 232-8603 or 1-800-451-6027 (Indiana Residents Only) http://www.in.gov/idem/water/permits/applications.html - A completed, signed, dated application form, - $50 permit application fee, - potentially affected persons list (this form), - and a topographic map indicating outfall location(s). PART A: NOTES Please list here any and all 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 any person who is later determined to be potentially affected could result in voiding our decision on procedural grounds. To ensure conformance with AOPA and to avoid reversal of a decision, please list all such parties. The letter attached to this form will further explain the requirements under the AOPA. Attach additional names and addresses on a separate sheet of paper, as needed. PART B: POTENTIALLY AFFECTED PERSONS NOTIFIED 1. 2. Name: Address: 3. 5. Name: Address: Name: Address: 4. Name: 6. Name: Address: Address: Name: Address: PART C: SIGNATURE & ADDITIONAL DETAILS PERMIT ACTION 7. Type of action (check one): NPDES Permit - 327 IAC 5 Land Application Permit - 327 IAC 6 Confined Feeding Approval - IC 13-18-10 Sewer Ban Waiver Request - 327 IAC 4 Operator Certification - 327 IAC 4 Pretreatment Permit - 327 IAC 5 Construction Permit - 327 IAC 3 FACILITY 8. Facility address: City: State: ZIP Code: SIGNATURE 9. Please complete the form by signing the following statement: "I Certify that to the best of my knowledge I have listed all potentially affected parties, as defined by IC 4-21.5." (Printed Name) (Title) (Signature) (Date Signed) (dd/mm/year) American LegalNet, Inc. www.FormsWorkflow.com FEE INFORMATION FOR NPDES PERMIT APPLICATIONS The following revised fees were established, pursuant to IC 13-18-20-12, effective March 18, 1994 to defray the costs of processing the permit applications for the NPDES permit program from all NPDES permit applicants: (1) When an application is filed with the Indiana Department of Environmental Management (IDEM), concerning a NPDES Permit action a fifty dollar ($50) application fee must be remitted. A permit action includes an application for an initial permit, the renewal of a permit, the modification of a permit, or a variance of a permit or permit limitation. If the application fee is not remitted the IDEM shall deny the permit application. (2) The permittee will remit the fee at the time the application, or a request for modification is filed with the IDEM. No fee will be assessed for permit modifications initiated by the IDEM. (3) For construction activity subject to 327 IAC 15-5, a fee of one hundred dollars ($100) shall be submitted with a Notice of Intent (NOI) letter. (4) The fees specified above will be payable to the Indiana Department of Environmental Management. Any fee submitted will not be refundable once substantive processing of the permit application has commenced. Additionally the issuance of (or existence of) a NPDES Permit will require the permittee to pay an annual fee for which billing will be made by the IDEM, all in accordance with Senate Enrolled Act 417, which was signed into law on March 18, 1994. This new schedule supersedes the fee schedule established in 327 IAC 5, 6, and 8. If there are any questions pertaining to the annual fee schedule contained in the regulation, they should be directed to the Program Management Section at 317/233-0569. Please send the completed forms and appropriate fee together with a cover letter to the Indiana Department of Environmental Management Office of Water Quality - NPDES Permits Section 100 North Senate Avenue Indianapolis, Indiana 46204 American LegalNet, Inc. www.FormsWorkflow.com