"Public Water System General Application for Approval or Permit" - Connecticut

Public Water System General Application for Approval or Permit is a legal document that was released by the Connecticut State Department of Public Health - a government authority operating within Connecticut.

Form Details:

  • Released on September 28, 2007;
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Download "Public Water System General Application for Approval or Permit" - Connecticut

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STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH
DRINKING WATER SECTION
PUBLIC WATER SYSTEM GENERAL APPLICATION FOR APPROVAL OR PERMIT
Instructions
Any regulated public water system (PWS) seeking an approval or permit (refer to list in Section C on following
page) must submit this general application to the Department in addition to the applicable specific applications
noted in Section C in order for the Department to initiate a review. This general application must be completed
by either the administrative official or certified operator for the PWS. Sections A through E must be completed.
Incomplete applications will be rejected. This general application form along with the applicable specific
applications noted in Section C may be obtained from the DPH Drinking Water Section’s web page by going to
the DPH webpage at
http://www.ct.gov/dph
and clicking on the Drinking Water Section Link. Each phase of a
multi-phase project requires a completed general application form.
Section A. Public Water System and Applicant Information
PWS Name:
For new PWS indicate proposed name of PWS. A PWSID# will be assigned by the Department for a new PWS
Project Name:
Project Address:
PWSID Number: CT
PWS Type (select one):
Community
NTNC
TNC
Town:
DPH Project Number (if known): ____________________
Print Name of PWS Administrative Official or Certified Operator:
Title:
Address:
Phone Number:
Fax Number:
E-mail Address:
_________________________________________________
____________________
Signature of PWS Administrative Official or Certified Operator:
DATE
Section B. Basis for Requesting Approval or Permit
(select all that apply)
Formal Enforcement Action
(Administrative Order, Consent Order, Notice of Violation (Civil Penalty))
Violation Identified in Sanitary Survey Report
Water Quality Exceedance
(select all that apply):
MCL,
Pb/Cu AL,
Secondary MCL,
Other:
Project Identified in Approved Water Supply Plan
Federal or State Grants or Loans
DWSRF
STEAP Funds
STAG Funds
Certificate of Public Convenience and Necessity (CPCN)
Proactive
(system improvements or enhancements)
Other:
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Rev 9/28/07
STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH
DRINKING WATER SECTION
PUBLIC WATER SYSTEM GENERAL APPLICATION FOR APPROVAL OR PERMIT
Instructions
Any regulated public water system (PWS) seeking an approval or permit (refer to list in Section C on following
page) must submit this general application to the Department in addition to the applicable specific applications
noted in Section C in order for the Department to initiate a review. This general application must be completed
by either the administrative official or certified operator for the PWS. Sections A through E must be completed.
Incomplete applications will be rejected. This general application form along with the applicable specific
applications noted in Section C may be obtained from the DPH Drinking Water Section’s web page by going to
the DPH webpage at
http://www.ct.gov/dph
and clicking on the Drinking Water Section Link. Each phase of a
multi-phase project requires a completed general application form.
Section A. Public Water System and Applicant Information
PWS Name:
For new PWS indicate proposed name of PWS. A PWSID# will be assigned by the Department for a new PWS
Project Name:
Project Address:
PWSID Number: CT
PWS Type (select one):
Community
NTNC
TNC
Town:
DPH Project Number (if known): ____________________
Print Name of PWS Administrative Official or Certified Operator:
Title:
Address:
Phone Number:
Fax Number:
E-mail Address:
_________________________________________________
____________________
Signature of PWS Administrative Official or Certified Operator:
DATE
Section B. Basis for Requesting Approval or Permit
(select all that apply)
Formal Enforcement Action
(Administrative Order, Consent Order, Notice of Violation (Civil Penalty))
Violation Identified in Sanitary Survey Report
Water Quality Exceedance
(select all that apply):
MCL,
Pb/Cu AL,
Secondary MCL,
Other:
Project Identified in Approved Water Supply Plan
Federal or State Grants or Loans
DWSRF
STEAP Funds
STAG Funds
Certificate of Public Convenience and Necessity (CPCN)
Proactive
(system improvements or enhancements)
Other:
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Rev 9/28/07
PUBLIC WATER SYSTEM GENERAL APPLICATION FOR APPROVAL OR PERMIT
Section C. Type of Approval or Permit Requested
(select all that apply)
Source
Treatment
Distribution
Well Site
Activated Carbon Adsorption
Consolidation of System(s)
(must submit Application
for a Public Water System Well Site
(includes the addition of new systems)
Aeration
Approval)
Interconnection Between
Arsenic Removal
Well Construction and Yield
Existing Systems
(refer to General Terms for Well Site
Chemical Changes
Pressure Reduction Valves
Development guidance document)
(PRV)
Chemical Corrosion Control
Well Water Quality
(refer to Water
Pumping Station
Quality Monitoring of Proposed/New
Contact Time (CT) Evaluation
Sources of Supply guidance document)
Storage Tank
Disinfection
Groundwater Under the Direct
Water Main
(only if associated with
Chemical
Influence of Surface Water
pumping stations, storage facilities,
(GWUDI) Demonstration Study
Ultraviolet Light (UV)
treatment facilities, sources of supply or
(refer to Determination of Groundwater
funded by a State or Federal grant/loan -
Other _____________________
Under The Direct Influence of Surface
must submit water main application)
Water criteria)
Ion Exchange
Other:
Source Improvements
Iron/Manganese, Iron Bacteria
(including well pit improvements)
Control
Source Abandonment Permit
General
Aeration
(must submit Source Abandonment Permit
Greensand filter
CPCN – Phase 1A
Application)
Ion Exchange
Water Company Owned Lands
CPCN – Phase 1B
Oxidation
Permit-Change in Use
(must submit
CPCN – Phase II
Water Company Land Permit Application &
Sequestering
Application Supplement)
Water Supply Plan
Other _____________________
Water Company Land Sale or
DWSRF Eligibility Application
Membrane Filtration / Reverse
Transfer of a Water Company
(must
Osmosis
DWSRF Engineering
submit Water Company Land Permit
Application & Application Supplement)
Agreement (Pre-Award)
pH Adjustment
Recreation Use Permit of Water
DWSRF Full Loan Application
Chemical
Company Owned Lands
(must
DWSRF Pre-Bid Construction
Calcite Filter
submit Permit Application for Recreational
Contract
Activity on Reservoir)
Other _____________________
Storm Water Discharge Permit
DWSRF Post-Bid Documents
Pilot Study
(must submit detailed site plan of proposed
and Information
storm water discharge, refer to RCSA
Radiological Removal
(Rad 226,
Sampling Plan
Section 19-13-B32i)
(refer to DWS web
Rad 228, Uranium, Gross Alpha)
page for instructions, form, and guidance)
Raw Water Pumping Station
Surface Water Treatment Plant-
Water System Improvements
coagulation, flocculation,
Raw Water Transmission Main
Study
(must submit detailed engineering
sedimentation/clarification, filtration
(must submit Water Main Application)
report)
Treatment Residuals/Backwash
Other:
Sale of Excess Water Permit
Wastewater Management
(must submit Sale of Excess Water Permit
Application)
Other:
NOTE: Detailed plans and
Other:
supporting documents must be
.
submitted at the time of application
for all projects
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PUBLIC WATER SYSTEM GENERAL APPLICATION FOR APPROVAL OR PERMIT
Section D. Project Description
Provide a detailed description of the proposed project
:
(or attach summary from engineering report if available)
Section E. Financial Commitment
Has a funding source been identified for this project?
Yes
No
N/A
If yes, briefly describe the source:
Anticipated Start Date of Construction:
/
/
(MM / DD / YY)
Drinking Water Section Use Only
Date Stamped: _____________________________________
Assigned Staff Person: _______________________________
Project No: _____________________
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