Form 489 "Water Supply Permit Application (Modification)" - Alabama

What Is Form 489?

This is a legal form that was released by the Alabama Department of Education - a government authority operating within Alabama. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2002;
  • The latest edition provided by the Alabama Department of Education;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 489 by clicking the link below or browse more documents and templates provided by the Alabama Department of Education.

ADVERTISEMENT
ADVERTISEMENT

Download Form 489 "Water Supply Permit Application (Modification)" - Alabama

Download PDF

Fill PDF online

Rate (4.4 / 5) 74 votes
WATER SUPPLY PERMIT APPLICATION
(MODIFICATION)
PART I – GENERAL:
This application shall be submitted when a water supply permit modification is requested and/or required
by ADEM Division 7 Regulations.
Please complete the application by providing all requested
information in the appropriate blanks for all applicable areas. Incomplete applications will be returned to
the applicant.
(TYPE ALL INFORMATION UNLESS OTHERWISE INSTRUCTED).
Current ADEM Operating Permit Number
Expiration Date
/
/
Merger of existing water systems permitted by ADEM?
YES
NO
If YES: PWSID System #1
PWSID System #2
Change of ownership/name change of an existing water system permitted by ADEM?
YES
NO
If YES: Current Legal Name of System
PWSID Number:
New Legal Name of System
Legal Name of System:
(Corporation, City Authority, Governmental Body, etc.)
Mailing Address:
Street or P. O. Box No.
City
County
State
Zip
Telephone #: (
)
Emer. Tel. #: (
)
Fax # (
)
E-Mail Address:
Certified Operator:
Operator Identification Number:
I certify that I have personally examined and am familiar with the information submitted in this application and all
attachments and that, based on my inquiry of those persons immediately responsible for obtaining the information
contained in the application. I believe that the information is true, accurate and complete. I am aware that
submitting false or incorrect information, are grounds for denial of the permit.
Print Name of Responsible Authority (Chairman/Mayor/Owner)
Title
Signature of Chairman/Mayor/Owner
Date
A Permit Application Fee must be submitted with this application.
The application must be mailed to:
ADEM-Drinking Water Branch
PO Box 301463
Montgomery, Alabama 36130-1463
1
ADEM Form #489 8/02
WATER SUPPLY PERMIT APPLICATION
(MODIFICATION)
PART I – GENERAL:
This application shall be submitted when a water supply permit modification is requested and/or required
by ADEM Division 7 Regulations.
Please complete the application by providing all requested
information in the appropriate blanks for all applicable areas. Incomplete applications will be returned to
the applicant.
(TYPE ALL INFORMATION UNLESS OTHERWISE INSTRUCTED).
Current ADEM Operating Permit Number
Expiration Date
/
/
Merger of existing water systems permitted by ADEM?
YES
NO
If YES: PWSID System #1
PWSID System #2
Change of ownership/name change of an existing water system permitted by ADEM?
YES
NO
If YES: Current Legal Name of System
PWSID Number:
New Legal Name of System
Legal Name of System:
(Corporation, City Authority, Governmental Body, etc.)
Mailing Address:
Street or P. O. Box No.
City
County
State
Zip
Telephone #: (
)
Emer. Tel. #: (
)
Fax # (
)
E-Mail Address:
Certified Operator:
Operator Identification Number:
I certify that I have personally examined and am familiar with the information submitted in this application and all
attachments and that, based on my inquiry of those persons immediately responsible for obtaining the information
contained in the application. I believe that the information is true, accurate and complete. I am aware that
submitting false or incorrect information, are grounds for denial of the permit.
Print Name of Responsible Authority (Chairman/Mayor/Owner)
Title
Signature of Chairman/Mayor/Owner
Date
A Permit Application Fee must be submitted with this application.
The application must be mailed to:
ADEM-Drinking Water Branch
PO Box 301463
Montgomery, Alabama 36130-1463
1
ADEM Form #489 8/02
Complete this side to reflect new or added facilities not included in the existing operating permit.
PART II – RAW WATER SOURCES:
(Go to PART III if there are no raw water sources in the system.)
Name
Aquifer/Depth (GW)
Permitted
Chemicals Fed/
Filtered
Raw Water Source (SW)
Capacity
Treatment Provided
(Y/N)
___________________
________________________
________
__________________
_______
___________________
________________________
________
__________________
_______
___________________
________________________
________
__________________
_______
___________________
________________________
________
__________________
_______
___________________
________________________
________
__________________
_______
___________________
________________________
________
__________________
_______
2
Filtration Rate _________ gpm/ft
Required CT _________ hours @ _________ mg/l chlorine
Total Clearwell Capacity _______________ MG
Are Clearwells Baffled (Y/N) _________
NOTE: Include chemicals used (chlorine, lime, soda ash, etc.) and physical processes used (aeration,
2
sedimentation, filtration, etc.) If treatment includes filtration, include permitted filtration rate (gpm/ft
)
PART III-DISTRIBUTION SYSTEM:
DIST. TANKS
TYPE
OVERFLOW ELEV.
VOLUME
(Name or No.)
(Elev/Grnd/Pres)
(Feet, MSL)
(Gallons)
DIST. PUMPING STATIONS *
CAPACITY
RECHLORINATION?
(Name/Location)
(gpm)
(Yes/No)
Identify hydropneumatic pumpstations with “P”
Number of Additional Customers
Total Number of Customers
TYPE OF WATER MAINS (Circle)
APPROXIMATE MILES OF MAIN (List by Type)
(Check)
Cast/Ductile Iron
Asbestos Cement
PVC
Other
NOTE: Attach additional sheets for each section, as needed.
2
ADEM Form #489 8/02
Page of 2