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

This document contains official instructions for Form DPH-PWS-SCREEN, Public Water System Screening Form - a form released and collected by the Connecticut State Department of Public Health. An up-to-date fillable Form DPH-PWS-SCREEN is available for download through this link.

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STATE OF CONNECTICUT
DEPARTMENT OF PUBLIC HEALTH
PUBLIC WATER SYSTEM SCREENING FORM
Instructions
Connecticut General Statutes (CGS) §16-262m(a), defines a water company as: “As used in this section and
section 8-25a, "water company" means a corporation, company, association, joint stock association, partnership,
municipality, other entity or person, or lessee thereof, owning, leasing, maintaining, operating, managing or
controlling any pond, lake, reservoir, stream, well or distributing plant or system employed for the purpose of
supplying water to fifteen or more service connections or twenty-five or more persons on a regular basis.”
Such proposed water companies must obtain a Certificate of Public Convenience and Necessity (CPCN) prior to
any construction of the water system. CGS § 8-25a requires that: “No proposal for a development using water
supplied by a company incorporated on or after October 1, 1984, shall be approved by a planning commission or
combined planning and zoning commission unless such company has been issued a certificate pursuant to section
16-262m. The municipality in which the planning commission or combined planning and zoning commission is
located shall be responsible for the operation of any water company created without a certificate after October 1,
1984.”
The Regulations of Connecticut State Agencies (RSCA) § 19-13-B102(a)(65) defines a Public Water System as
“any water company supplying water to 15 or more consumers or 25 or more persons, based on the "Design
Population" as defined in section 16-262m-8(a)(3) of the Regulations of Connecticut State Agencies, jointly
administered by the department and the Public Utilities Regulatory Authority, daily at least 60 days of the year that
does not meet all of the following conditions:
(A)
Consists only of distribution and storage facilities;
(B)
Does not have any treatment facilities, other than those for non-potable use;
(C)
Obtains all of its water from, but is not owned or operated by, a public water system;
(D)
Does not separately bill the consumers for water use or consumption; and
(E)
Is not a carrier which conveys passengers in interstate commerce;”
This form is used to determine if a proposed project or a change in operation at an existing facility will result in the
creation of a new water company or public water system or change the status of an existing public water system.
Section 1 – Basic Information
• Project Type: Mark appropriate box indicating the type project.
Proposed Development: New construction or development that will serve drinking water to the public;
Conversion of Existing Structure/Property: The change in use of an existing structure and/or property
resulting in drinking water being served to the public;
Unclassified Facility Currently in Operation: Previously unclassified water system that is currently in
operation and is providing drinking water to the public;
PWS Classification Review: Request for Department review of a public water system (PWS) where the
operational status or population being served has changed.
• Anticipated Start Date: For proposed developments and conversions, the anticipated date that the proposed
water system will begin serving drinking water to the public.
• Name of Facility: Name of proposed facility or existing public drinking water system. This will be used to identify
the facility in correspondence from this office.
• PWS ID #: If known, provide the PWS identification number for this facility.
• Proposed/Current Maximum daily population served: The proposed or current maximum number of persons
to have water made available to them on a daily basis.
• Proposed/Current Building Capacity: The maximum number of individuals allowed by the occupancy permit.
• Customer of a water company? Indicate if this facility is or will be a customer of a water company. (It is not a
customer of a water company if the facility is served exclusively by an on-site well)
DPH-PWS-SCREEN-INST
Page 1 of 3
Rev. 10/09/2013
STATE OF CONNECTICUT
DEPARTMENT OF PUBLIC HEALTH
PUBLIC WATER SYSTEM SCREENING FORM
Instructions
Connecticut General Statutes (CGS) §16-262m(a), defines a water company as: “As used in this section and
section 8-25a, "water company" means a corporation, company, association, joint stock association, partnership,
municipality, other entity or person, or lessee thereof, owning, leasing, maintaining, operating, managing or
controlling any pond, lake, reservoir, stream, well or distributing plant or system employed for the purpose of
supplying water to fifteen or more service connections or twenty-five or more persons on a regular basis.”
Such proposed water companies must obtain a Certificate of Public Convenience and Necessity (CPCN) prior to
any construction of the water system. CGS § 8-25a requires that: “No proposal for a development using water
supplied by a company incorporated on or after October 1, 1984, shall be approved by a planning commission or
combined planning and zoning commission unless such company has been issued a certificate pursuant to section
16-262m. The municipality in which the planning commission or combined planning and zoning commission is
located shall be responsible for the operation of any water company created without a certificate after October 1,
1984.”
The Regulations of Connecticut State Agencies (RSCA) § 19-13-B102(a)(65) defines a Public Water System as
“any water company supplying water to 15 or more consumers or 25 or more persons, based on the "Design
Population" as defined in section 16-262m-8(a)(3) of the Regulations of Connecticut State Agencies, jointly
administered by the department and the Public Utilities Regulatory Authority, daily at least 60 days of the year that
does not meet all of the following conditions:
(A)
Consists only of distribution and storage facilities;
(B)
Does not have any treatment facilities, other than those for non-potable use;
(C)
Obtains all of its water from, but is not owned or operated by, a public water system;
(D)
Does not separately bill the consumers for water use or consumption; and
(E)
Is not a carrier which conveys passengers in interstate commerce;”
This form is used to determine if a proposed project or a change in operation at an existing facility will result in the
creation of a new water company or public water system or change the status of an existing public water system.
Section 1 – Basic Information
• Project Type: Mark appropriate box indicating the type project.
Proposed Development: New construction or development that will serve drinking water to the public;
Conversion of Existing Structure/Property: The change in use of an existing structure and/or property
resulting in drinking water being served to the public;
Unclassified Facility Currently in Operation: Previously unclassified water system that is currently in
operation and is providing drinking water to the public;
PWS Classification Review: Request for Department review of a public water system (PWS) where the
operational status or population being served has changed.
• Anticipated Start Date: For proposed developments and conversions, the anticipated date that the proposed
water system will begin serving drinking water to the public.
• Name of Facility: Name of proposed facility or existing public drinking water system. This will be used to identify
the facility in correspondence from this office.
• PWS ID #: If known, provide the PWS identification number for this facility.
• Proposed/Current Maximum daily population served: The proposed or current maximum number of persons
to have water made available to them on a daily basis.
• Proposed/Current Building Capacity: The maximum number of individuals allowed by the occupancy permit.
• Customer of a water company? Indicate if this facility is or will be a customer of a water company. (It is not a
customer of a water company if the facility is served exclusively by an on-site well)
DPH-PWS-SCREEN-INST
Page 1 of 3
Rev. 10/09/2013
• Property Address: The physical location of the existing or proposed facility.
• Number of service connections: The number of independent structures or housing units that are proposed.
Separate the total number and indicate in the appropriate space how many of each type of connection.
•
“Residential” refers to housing facilities (homes, apartments, condos – permanent living quarters)
•
“Non-Res” may refer to businesses, schools, day care facilities, food service establishments, offices, etc.
(i.e. anything that is not residential).
• Proposed/Current Daycare Capacity: The existing or proposed licensed daycare capacity. For more
information, refer to the DPH Child Day Care Licensing program: http://www.ct.gov/dph/daycare.
• Number of days per year facility is/will be operational: The total number of days that drinking water is or is
anticipated to be made available to the public during a calendar year (days do not need to be consecutive).
• Description of Project: Provide a brief description of the project or a reason for requesting a PWS classification
review. Attach additional pages to the form if necessary.
Section 2 – Facility Information
• Will or does the facility supply water for domestic use to its customers, visitors and/or members?: Water
for domestic use is considered the availability of restrooms, hand washing, sink access, 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/business supplied by the water system daily at 60 days
out of the year?: Use the total number of persons at the facilities/businesses in any capacity (i.e. visiting,
working, etc.) when determining. The 60 days a year do not need to be consecutive.
• 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: Total number of persons regularly using the facilities
for at least six months a year, six months does not need to be consecutive (i.e. employees, students, etc.).
• Number of persons whose primary residence is or will be supplied by the facility based on design
population: Calculate and provide the total residential population that is or will be served by the facility. RCSA §
16-262m-8(a)(3) defines design population as “the estimated number of people per service connection,
calculated as follows, unless specific circumstances dictate otherwise:
Type of service
Design Population Per Service Connection
Single family dwelling
4
(Over 3 bedrooms add 1 person per additional bedroom)
Multi-dwelling (i.e. apartments, elderly housing, duplexes,
townhouses and residential condominiums)
One bedroom unit
2
Two bedroom unit
3
Three bedroom unit
4
(over 3 bedrooms add 1 person per additional bedroom)
Mobile Homes or Trailers
2.5
Convalescent Homes
Use Number of Beds
All other components described in 16-262m-1 (a)
Use Estimated Population”
• Facility annual operating period (begin/end dates of operation): The dates between which the water system
is physically operating on an annual basis. If the well water system is not physically disconnected at some point
during the year, it is considered year round.
• Type of Facilities (check all that apply): Check all types that apply. If not found on the list, check ‘other’ and
specify in the space provided.
Section 3 – Property Owner Contact Information
This section contains the contact information for the owner of the property that is the subject of the project. This
contact must be the current owner of the property and will receive all correspondence related to the project. Failure
to provide complete and accurate contact information may result in delays during project review.
DPH-PWS-SCREEN-INST
Page 2 of 3
Rev. 10/09/2013
The Drinking Water Section (DWS) requires each public water system to identify one entity that has the legal
authority to act on behalf of the water system. This entity may be an individual, property owner, sole proprietor,
partnership, limited partnership, corporation, LLC, or government entity but not a tenant who has no ownership or
legal rights to the public water system or water company. In all cases, the DWS requires that an individual person
be named to represent the organization. This contact will receive all general and legal correspondence from the
DPH. In addition, the DWS is requesting that all contacts maintain an active email address on file with the
Department to improve messaging and communication, especially in the event of an emergency.
Section 4 – Certification Statement
Please read the certification statement provided and sign and date in the spaces provided. Signatures must be that
of the property owner or legal contact for the water system.
Print your name in the space provided below
‘signature’.
Please submit completed forms and all Supporting Documents to:
DWDCompliance@ct.gov
or
Department of Public Health
Drinking Water Section
410 Capitol Avenue, MS#51WAT
P.O. Box 340308
Hartford, CT 06134-0308
DPH-PWS-SCREEN-INST
Page 3 of 3
Rev. 10/09/2013
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