"Application for Well Permit Exception" - Connecticut

Application for Well Permit Exception 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 February 1, 2016;
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Download "Application for Well Permit Exception" - Connecticut

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STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH
DRINKING WATER SECTION
APPLICATION FOR WELL PERMIT EXCEPTION PURSUANT TO SECTION 19-13-B51M OF THE
REGULATIONS OF CONNECTICUT STATE AGENCIES
The Regulations Of Connecticut State Agencies (RCSA), Section 19-13-B51m(b) prohibits a local director of
health from issuing a well drilling permit at residential premises where the water will be used for human
consumption, or at non-residential premises where the water may be used for human consumption, when a
community water system is deemed available within two hundred feet, measured along a street, alley or
easement from the parcel’s boundary. In some circumstances, pursuant to RCSA Section 19-13-B51m(c) an
exception may be granted to the above mentioned section.
To apply for an exception, the applicant shall complete Section #1 of this application and have the water
company complete Section #2 on the second page. Then the local health department, upon a preliminary
review of the application shall complete Section #3.
The completed application may be emailed to
DPH.SourceProtection@ct.gov
or it may be mailed to the following address:
Department of Public Health
Drinking Water Section, Source Assessment and Protection Unit
410 Capitol Avenue MS# 51 WAT
P O Box 3403038
Hartford, CT 06134-0308
1. Well Applicant Information:
Property Address:
_____________________________________________________________________________________________
Applicant Name and Address:
_______________________________________________________________________
Type of property:
single-family residential
residential
commercial
Provide all reasons that may justify the well permit exception request, particularly construction problems.
Supporting documentation must be submitted along with the justification. Attach additional pages if
necessary.
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
_________________________________________________
____________________
Signature of well applicant
DATE
1 of 2
Rev 2/16
STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH
DRINKING WATER SECTION
APPLICATION FOR WELL PERMIT EXCEPTION PURSUANT TO SECTION 19-13-B51M OF THE
REGULATIONS OF CONNECTICUT STATE AGENCIES
The Regulations Of Connecticut State Agencies (RCSA), Section 19-13-B51m(b) prohibits a local director of
health from issuing a well drilling permit at residential premises where the water will be used for human
consumption, or at non-residential premises where the water may be used for human consumption, when a
community water system is deemed available within two hundred feet, measured along a street, alley or
easement from the parcel’s boundary. In some circumstances, pursuant to RCSA Section 19-13-B51m(c) an
exception may be granted to the above mentioned section.
To apply for an exception, the applicant shall complete Section #1 of this application and have the water
company complete Section #2 on the second page. Then the local health department, upon a preliminary
review of the application shall complete Section #3.
The completed application may be emailed to
DPH.SourceProtection@ct.gov
or it may be mailed to the following address:
Department of Public Health
Drinking Water Section, Source Assessment and Protection Unit
410 Capitol Avenue MS# 51 WAT
P O Box 3403038
Hartford, CT 06134-0308
1. Well Applicant Information:
Property Address:
_____________________________________________________________________________________________
Applicant Name and Address:
_______________________________________________________________________
Type of property:
single-family residential
residential
commercial
Provide all reasons that may justify the well permit exception request, particularly construction problems.
Supporting documentation must be submitted along with the justification. Attach additional pages if
necessary.
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
_________________________________________________
____________________
Signature of well applicant
DATE
1 of 2
Rev 2/16
2. Community Public Water System (CPWS) available within 200 feet from the property line
CPWS Name and ID:
__________________________________________________________________________________________________________________
Is the property in discussion currently served by the CPWS?
Yes
No
If yes, be aware of the cross-connection protection requirements.
Will an exception, if granted, adversely affect the purity and adequacy of the CPWS
water supply, or the service to the customers of the CPWS?
Yes
No
Is the CPWS able to provide adequate water supply service as requested by
the owner of the property located within their exclusive service area boundaries?
Yes
No
If no, all reasons and factors that prevent the CPWS from serving the property must be included. Attach
an additional letter with the explanation. Also indicate whether additional supply, storage and booster
facilities are necessary for providing proper service.
Does the CPWS recommend the issuance of the well permit exception?
Yes
No
_________________________________________________
____________________
Signature of CPWS Administrative Official or Certified Operator:
DATE
:
3. Local Health Department (LHD) with jurisdiction over the property
Can a well be located on the property pursuant to RCSA Section 19-13-B51d?
Yes
No
Is there any known particular concern with water quality or quantity in the area?
Yes
No
Indicate of type of sewage disposal proposed:
Septic system
Sewer
Is the lot in discussion part of a subdivision?
Yes
No
Does the LHD recommend the issuance of the well permit exception?
Yes
No
_________________________________________________
____________________
Signature of Local Director of Health
DATE
For additional information or questions regarding this application, please contact the Drinking Water Section at (860) 509-7333
Drinking Water Section Use Only
Received Date: _____________________________________
Closed Date:____________________
Application complete:
Yes
No
Assigned Staff Person: _______________________________
Approved
Denied
DPH Project Number: ________________________________
2 of 2
Rev. 2/16
Page of 2