"School Water System Evaluation Form" - Connecticut

School Water System Evaluation Form 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 October 26, 2011;
  • The latest edition currently provided by the Connecticut State Department of Public Health;
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Download "School Water System Evaluation Form" - Connecticut

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STATE OF CONNECTICUT - DEPARTMENT OF PUBLIC HEALTH
DEPARTMENT OF CONSTRUCTION SERVICES - SCHOOL WATER SYSTEM EVALUATION FORM
This form is intended to evaluate whether or not additional information regarding the water supply system at this school
must be submitted to the Department of Public Health (DPH) - Drinking Water Section (DWS).
Background and instructions for completing the project evaluation form
INSTRUCTIONS FOR SCHOOLS/CONSULTANTS
This form is to be completed by the school applicant and submitted to the Department of Construction Services (DCS)
along with all other DCS application materials. Submit a completed copy of this form to DPH at the address below.
Each question on the form is Yes or No. Please answer to the best of your knowledge.
Changes to the scope of the project after this form has been completed may change the original determination regarding
the need to have materials reviewed by DPH. If changes are made, please submit an updated form to DCS and updated
form and, if necessary, project information, to DPH.
Regulatory Requirements That Affect School Projects
Regulations of Connecticut State Agencies (RCSA) Section 19-13-B102(d) refers to public water system facility location
and review requirements for new installation.
Sec. 19-13-B102(d): Facility Location. Such as but not limited to treatment plants, pumping stations, storage tanks, etc.,
but not including water intakes and connecting pipelines. (1) New facilities are to be located: (A) Above the level of the one
hundred year flood. (B) Where chlorine gas will not be stored or used within three hundred feet of any residence. (C)
Where the facility is not likely to be subject to fires or other natural or manmade disasters.
Sec. 19-13-B102(d)(2): The state health department must be notified before entering into a financial commitment for a
new public water system or increasing the capacity of an existing public water system, and the approval of the state health
department must be obtained before any construction is begun. This includes construction of supply and treatment works,
transmission lines, storage tanks, pumping stations and other works of sanitary significance. It does not include the
routine extension of laterals or tapping of new service connections.
Name of School:
Town:
Please answer the following question:
(circle your answer)
Is this school supplied by its own on-site well water system?
Yes
No
If Yes, complete page 2 of this form, sign, and submit both pages to DCS and DPH.
If No, submit a letter from the water company supplying water (with their PWS identification #) indicating whether or
not they have sufficient domestic supply to continue to serve these facilities after all modifications are complete,
along with a signed copy of this form (it is not necessary to complete page 2 with the exception of the signature).
If UNKNOWN, please refer to the DWS website and search for the school name under the "Public Water System
Classification and Inventory" section. There is a list of all schools that are public water systems.
SUBMITTAL OF INFORMATION TO DEPARTMENT OF PUBLIC HEALTH
Send to:
State of CT - Department of Public Health
Drinking Water Section
410 Capitol Avenue, MS# 51WAT
Phone: 860-509-7333
PO Box 340308
Fax: 860-509-7359
Hartford, CT 06134-0308
rev 10/26/11
Page 1 of 2
STATE OF CONNECTICUT - DEPARTMENT OF PUBLIC HEALTH
DEPARTMENT OF CONSTRUCTION SERVICES - SCHOOL WATER SYSTEM EVALUATION FORM
This form is intended to evaluate whether or not additional information regarding the water supply system at this school
must be submitted to the Department of Public Health (DPH) - Drinking Water Section (DWS).
Background and instructions for completing the project evaluation form
INSTRUCTIONS FOR SCHOOLS/CONSULTANTS
This form is to be completed by the school applicant and submitted to the Department of Construction Services (DCS)
along with all other DCS application materials. Submit a completed copy of this form to DPH at the address below.
Each question on the form is Yes or No. Please answer to the best of your knowledge.
Changes to the scope of the project after this form has been completed may change the original determination regarding
the need to have materials reviewed by DPH. If changes are made, please submit an updated form to DCS and updated
form and, if necessary, project information, to DPH.
Regulatory Requirements That Affect School Projects
Regulations of Connecticut State Agencies (RCSA) Section 19-13-B102(d) refers to public water system facility location
and review requirements for new installation.
Sec. 19-13-B102(d): Facility Location. Such as but not limited to treatment plants, pumping stations, storage tanks, etc.,
but not including water intakes and connecting pipelines. (1) New facilities are to be located: (A) Above the level of the one
hundred year flood. (B) Where chlorine gas will not be stored or used within three hundred feet of any residence. (C)
Where the facility is not likely to be subject to fires or other natural or manmade disasters.
Sec. 19-13-B102(d)(2): The state health department must be notified before entering into a financial commitment for a
new public water system or increasing the capacity of an existing public water system, and the approval of the state health
department must be obtained before any construction is begun. This includes construction of supply and treatment works,
transmission lines, storage tanks, pumping stations and other works of sanitary significance. It does not include the
routine extension of laterals or tapping of new service connections.
Name of School:
Town:
Please answer the following question:
(circle your answer)
Is this school supplied by its own on-site well water system?
Yes
No
If Yes, complete page 2 of this form, sign, and submit both pages to DCS and DPH.
If No, submit a letter from the water company supplying water (with their PWS identification #) indicating whether or
not they have sufficient domestic supply to continue to serve these facilities after all modifications are complete,
along with a signed copy of this form (it is not necessary to complete page 2 with the exception of the signature).
If UNKNOWN, please refer to the DWS website and search for the school name under the "Public Water System
Classification and Inventory" section. There is a list of all schools that are public water systems.
SUBMITTAL OF INFORMATION TO DEPARTMENT OF PUBLIC HEALTH
Send to:
State of CT - Department of Public Health
Drinking Water Section
410 Capitol Avenue, MS# 51WAT
Phone: 860-509-7333
PO Box 340308
Fax: 860-509-7359
Hartford, CT 06134-0308
rev 10/26/11
Page 1 of 2
STATE OF CONNECTICUT - DEPARTMENT OF PUBLIC HEALTH
DEPARTMENT OF CONSTRUCTION SERVICES - SCHOOL WATER SYSTEM EVALUATION FORM
Please refer to the Background and Instructions (see page 1) for additional information about this form. If the school facility is
supplied water from a water company you do not need to complete this page of the form with the exception of the signature
area below. This page of the form is only to be completed if the school facility is supplied water by an on-site water supply
system.
The following questions will help to evaluate if the project will require Department of Public Health review and/or approval prior
to construction and installation.
Name of School:
Address of School:
Town:
Public Water System ID #:
Will this project include the following:
Circle one
1 New source of water supply (i.e. one that is not currently in use)
Yes
No
2 New water storage tank(s)
Yes
No
3 New water pumping station
Yes
No
4 New water treatment system
Yes
No
5 Change in existing water treatment components or chemical
Yes
No
6 Increase in building capacity (student & staff population) or new facility
Yes
No
Also note that many water system components, including buried water storage tanks and wells, have minimum separating
distance requirements to sources of pollution, such as fuel oil storage tanks. The following questions will help evaluate if the
proposed project activites affect these distances.
7 Will a buried water storage tank (existing or proposed) be within:
a.
50 feet of any part of a subsurface sewage disposal system or sanitary sewer
Yes
No
b.
25 feet of the nearest watercourse or storm drain
Yes
No
c.
25 feet of other sources of pollution (includes fuel storage tanks & lines)
Yes
No
8 Will a source of supply (well; existing or proposed) be within:
if you do not have a well in this category, circle here:
NA
a.
For a pump rate of <10 gal. per min. (gpm):
75 feet of any part of a subsurface sewage disposal system or sanitary sewer*
Yes
No
75 feet of fuel oil storage tank or any part of the heating system
Yes
No
25 feet of the nearest watercourse, annual high water or storm drain
Yes
No
if you do not have a well in this category, circle here:
NA
b.
For a pump rate of 10-50 gpm:
150 feet of any part of a subsurface sewage disposal system or sanitary sewer*
Yes
No
150 feet of fuel oil storage tank or any part of the heating system
Yes
No
50 feet of the nearest watercourse, annual high water or storm drain
Yes
No
if you do not have a well in this category, circle here:
NA
c.
For a pump rate of >50 gpm:
200 feet of any part of a subsurface sewage disposal system or sanitary sewer*
Yes
No
200 feet of fuel oil storage tank or any part of the heating system
Yes
No
50 feet of the nearest watercourse, annual high water or storm drain
Yes
No
Changes to the scope of the project after this form has been completed may change the original determination regarding the
need to have materials reviewed by the DPH. If changes are made, please submit an updated form to DCS and updated
form and project information to DPH.
* lesser separating distances may apply if sewer pipe is considered tight pipe
Name of individual completing this form:
Signature:
E-mail:
Date:
Address:
Phone:
Relationship to School:
Date Reviewed by DPH:
Staff Initials:
DPH Approval Req?
Yes
No
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