Form DPH-PWS-SCREEN "Public Water System Screening Form" - Connecticut

What Is Form DPH-PWS-SCREEN?

This is a legal form that was released by the Connecticut State Department of Public Health - a government authority operating within Connecticut. Check the official instructions before completing and submitting the form.

Form Details:

  • Released on October 17, 2013;
  • The latest edition provided by the Connecticut State Department of Public Health;
  • 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 DPH-PWS-SCREEN by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Public Health.

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Download Form DPH-PWS-SCREEN "Public Water System Screening Form" - Connecticut

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STATE OF CONNECTICUT
DEPARTMENT OF PUBLIC HEALTH
PUBLIC WATER SYSTEM SCREENING FORM
Pursuant to CGS Sections 16-262m & 8-25a and RCSA Section 19-13-B102
Section 1: Basic Information
Project Type:
Conversion of Existing Structure/Property
Proposed Development
Unclassified Facility Currently in Operation
PWS Classification Review
Anticipated Start Date:
Name of Facility
Proposed/Current
Customer of a
Proposed/Current
Maximum Daily
water company?
Building Capacity
Population Served
PWS ID #
Yes
No
CT
Property Address
Number of Service
Number of days per
Proposed/current
Connections:
year facility is/will be
daycare capacity:
operational:
City
State
ZIP Code
Residential Non-Res
Description of Project (Attach additional pages if necessary):
Section 2: Facility Information
Will or does the facility supply water for domestic use to its customers, visitors and/or members?:
Yes
No
(domestic use is considered restrooms, hand washing, sinks, drinking fountains, etc.)
Will or do at least 25 persons (including employees, customers, parishioners, visitors, etc. but not necessarily the same
persons) visit the facilities/businesses supplied by the water system daily at least 60 days out of the year?
Yes
No
Number of same persons (i.e. employees, students, but not residents) that will or do regularly use the facility on a daily
basis for at least six months a year:
Number of persons whose primary residence is or will be supplied by the facility based on design population:
Facility annual operating period (begin/end dates of operation): From
(month/day) to
(month/day)
Type of Facilities (Check all that apply)
Residential
School
Food Service
Day Care
Campground
Medical/Dental
Professional Office
Youth Camp
Gas Station
Retail
Manufacturing
Place of Worship
Park/Recreation Area
Other - specify:
Section 3: Property Owner Contact Information
Name
Legal Contact Person (if owner is not an individual)
Mailing Address
City
State
ZIP Code
Telephone
Fax
Emergency Phone
E-mail Address
Section 4: Certification Statement
I certify to the best of my knowledge that the information provided in this application is complete and correct. I understand
that the information I provide will be used by the Department of Public Health, Drinking Water Section to determine if a
proposed project or existing facility will be or is considered a water company and a public water system and to also
determine the most appropriate steps for initiating the regulatory process.
Signature of Property Owner/Legal Contact:
Date:
Printed Name of Property Owner/Legal Contact:
FOR DWS USE ONLY
CPCN:
Yes
No
Conversion:
Yes
No
Reactivation of former PWS:
Yes
No
New Water System (currently in operation):
Yes
No
PWS Classification Review:
Yes
No
System Classification:
C
NTNC
TNC
NP Date of determination:
DWS Project #:
DPH-PWS-SCREEN
Page 1 of 1
Rev. 10/17/2013
STATE OF CONNECTICUT
DEPARTMENT OF PUBLIC HEALTH
PUBLIC WATER SYSTEM SCREENING FORM
Pursuant to CGS Sections 16-262m & 8-25a and RCSA Section 19-13-B102
Section 1: Basic Information
Project Type:
Conversion of Existing Structure/Property
Proposed Development
Unclassified Facility Currently in Operation
PWS Classification Review
Anticipated Start Date:
Name of Facility
Proposed/Current
Customer of a
Proposed/Current
Maximum Daily
water company?
Building Capacity
Population Served
PWS ID #
Yes
No
CT
Property Address
Number of Service
Number of days per
Proposed/current
Connections:
year facility is/will be
daycare capacity:
operational:
City
State
ZIP Code
Residential Non-Res
Description of Project (Attach additional pages if necessary):
Section 2: Facility Information
Will or does the facility supply water for domestic use to its customers, visitors and/or members?:
Yes
No
(domestic use is considered restrooms, hand washing, sinks, drinking fountains, etc.)
Will or do at least 25 persons (including employees, customers, parishioners, visitors, etc. but not necessarily the same
persons) visit the facilities/businesses supplied by the water system daily at least 60 days out of the year?
Yes
No
Number of same persons (i.e. employees, students, but not residents) that will or do regularly use the facility on a daily
basis for at least six months a year:
Number of persons whose primary residence is or will be supplied by the facility based on design population:
Facility annual operating period (begin/end dates of operation): From
(month/day) to
(month/day)
Type of Facilities (Check all that apply)
Residential
School
Food Service
Day Care
Campground
Medical/Dental
Professional Office
Youth Camp
Gas Station
Retail
Manufacturing
Place of Worship
Park/Recreation Area
Other - specify:
Section 3: Property Owner Contact Information
Name
Legal Contact Person (if owner is not an individual)
Mailing Address
City
State
ZIP Code
Telephone
Fax
Emergency Phone
E-mail Address
Section 4: Certification Statement
I certify to the best of my knowledge that the information provided in this application is complete and correct. I understand
that the information I provide will be used by the Department of Public Health, Drinking Water Section to determine if a
proposed project or existing facility will be or is considered a water company and a public water system and to also
determine the most appropriate steps for initiating the regulatory process.
Signature of Property Owner/Legal Contact:
Date:
Printed Name of Property Owner/Legal Contact:
FOR DWS USE ONLY
CPCN:
Yes
No
Conversion:
Yes
No
Reactivation of former PWS:
Yes
No
New Water System (currently in operation):
Yes
No
PWS Classification Review:
Yes
No
System Classification:
C
NTNC
TNC
NP Date of determination:
DWS Project #:
DPH-PWS-SCREEN
Page 1 of 1
Rev. 10/17/2013