Form YG5453 "Application for a Permit to Operate a Large Public Drinking Water System" - Yukon, Canada

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Download Form YG5453 "Application for a Permit to Operate a Large Public Drinking Water System" - Yukon, Canada

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APPLICATION FOR A PERMIT TO OPERATE A
LARGE PUBLIC DRINKING WATER SYSTEM
The provision of this information will help to determine if your large drinking water system supplies safe water and meets
the requirements of the Drinking Water Regulation, under the Public Health & Safety Act.
SECTION 1: OWNER/PROPONENT INFORMATION
Legal Name of Owner
Contact Person
(Municipality, First Nation, Yukon Government, Business, other)
Mailing Address
City/Town/Village
Province/Territory
Postal Code
Telephone
Fax
Email
SECTION 2: WATER SYSTEM SITE INFORMATION
Name of Facility / Water System
Legal Description for Water Treatment Plant(s)
Lot
Quad
Plan
Municipal Address and GPS Location of Water Treatment Plant
(Street Name, Easting and Northing)
Maximum Number of Persons Served
Number of Connections
Number of Delivery Sites
(Piped System)
(Trucked System)
Average Water Demand
Production Capacity
Reservoir Capacity
(Litres/Day)
(Litres/Day)
(Litres)
Head Operator
Telephone
SECTION 3: SOURCE WATER SOURCE
Water Source:
Well(s)
Surface Water
Both well(s) and surface water
SECTION 4: WATER TREATMENT
Method(s) of Water Treatment
(e.g., chlorination, sediment filtration)
SECTION 5: EMERGENCY RESPONSE PLAN
The Emergency Response Plan for your Large Public Drinking Water System has been included with this application:
Y Y Y Y
/
M M
/
D D
Yes
No; expected date of delivery to Environmental Health Services _____________________
SECTION 6: ADDITIONAL INFORMATION
The following information must be submitted as part of your application. Please ensure you have attached a separate
document(s) which describes or provides information on each of the items below. If a section is not applicable, the
information does not have to be provided.
Description of Groundwater Sources (for each well)
• copy of well log
• depth of well
• date of construction
• pump specifications
• depth of casing
• material of construction of casing
• location, including GPS
• capacity of pump and well
• wellhead construction
• other relevant information,
• potential sources of contamination
• security to prevent unauthorized access
documents, diagrams, or pictures
YG(5453EQ)F2 Rev.07/2017
Page 1 of 2
Print
Clear
APPLICATION FOR A PERMIT TO OPERATE A
LARGE PUBLIC DRINKING WATER SYSTEM
The provision of this information will help to determine if your large drinking water system supplies safe water and meets
the requirements of the Drinking Water Regulation, under the Public Health & Safety Act.
SECTION 1: OWNER/PROPONENT INFORMATION
Legal Name of Owner
Contact Person
(Municipality, First Nation, Yukon Government, Business, other)
Mailing Address
City/Town/Village
Province/Territory
Postal Code
Telephone
Fax
Email
SECTION 2: WATER SYSTEM SITE INFORMATION
Name of Facility / Water System
Legal Description for Water Treatment Plant(s)
Lot
Quad
Plan
Municipal Address and GPS Location of Water Treatment Plant
(Street Name, Easting and Northing)
Maximum Number of Persons Served
Number of Connections
Number of Delivery Sites
(Piped System)
(Trucked System)
Average Water Demand
Production Capacity
Reservoir Capacity
(Litres/Day)
(Litres/Day)
(Litres)
Head Operator
Telephone
SECTION 3: SOURCE WATER SOURCE
Water Source:
Well(s)
Surface Water
Both well(s) and surface water
SECTION 4: WATER TREATMENT
Method(s) of Water Treatment
(e.g., chlorination, sediment filtration)
SECTION 5: EMERGENCY RESPONSE PLAN
The Emergency Response Plan for your Large Public Drinking Water System has been included with this application:
Y Y Y Y
/
M M
/
D D
Yes
No; expected date of delivery to Environmental Health Services _____________________
SECTION 6: ADDITIONAL INFORMATION
The following information must be submitted as part of your application. Please ensure you have attached a separate
document(s) which describes or provides information on each of the items below. If a section is not applicable, the
information does not have to be provided.
Description of Groundwater Sources (for each well)
• copy of well log
• depth of well
• date of construction
• pump specifications
• depth of casing
• material of construction of casing
• location, including GPS
• capacity of pump and well
• wellhead construction
• other relevant information,
• potential sources of contamination
• security to prevent unauthorized access
documents, diagrams, or pictures
YG(5453EQ)F2 Rev.07/2017
Page 1 of 2
Print
Clear
Description of Surface Water Sources
• name of water body
• potential sources of contamination
• other relevant information,
• length of intake pipe
documents, diagrams, or pictures
• protection of intake
• location of intake
Water Treatment Plant
• layout of water treatment plant
• location of equipment manuals and
• description(s) of water treatment
(provide a schematic)
written procedures (provide copies
equipment (i.e., type, size, capacity)
of procedures)
• description(s) of special provisions
• specifications of pump(s)
(e.g., separate chlorination room or
• description(s) of retention tank(s), which
• plans for provision of equipment
storage of chemicals)
should include material of construction,
and supplies during emergencies
capacity, water retention time
• provisions for cleaning, including
• other relevant information,
those for retention tanks
• Environmental Operators’ classification
documents, diagrams, or pictures
Certification Program (EOCP)
• pictures of visible infrastructure
Piped Distribution System
• number of service connections
• type of piping (i.e., material of
• location and construction of
construction, and age)
reservoirs
• layout of distribution system
(provide a schematic which shows
• free available chlorine records for
• EOCP classification
all loops and dead ends)
previous 3 months
• other relevant information,
• provisions for pipe flushing and repair
• information on rechlorination pump
documents, diagrams, or pictures
• population served
houses
Trucked Distribution System (for each truck)
• type of truck (eg. Freightliner)
• capacity of truck tank
• material of construction for water tank
• description of access port(s) and vents
• material of construction of water
• description of hose compartment
hose and nozzle
• location and type of backflow preventor
• delivery schedule (provide a copy)
• description of cleaning and disinfection
• other duties of water truck driver(s)
• location of equipment manuals
procedures, including frequencies
and written procedures (provide
• frequency of equipment manual and
• plans for provision of equipment and
copies of procedures)
procedure updates
supplies during emergencies
• provision for water truck storage
• pictures of each truck, showing label-
• free available chlorine records for
(see Section 82(1) of the Drinking
ing (signs), hose compartment (open
previous 3 months
Water Regulation)
and closed), access port(s), vent(s),
hose and nozzle, and any other
• pictures of truckfill station and water
• other relevant information,
important features
storage area
documents, and/or pictures
Operator Certification
• names of operators
• EOCP class of certification for
• dates of certifcation
each operator
• current status of certificate for
• other relevant information,
each operator
documents, and/or pictures
Bacteriological Sampling Program
• frequency of sampling (see Schedule
• location and description of all
• other relevant information,
C of the Drinking Water Regulation)
sampling points
documents, and/or pictures
Chemical Sampling Program
• frequency of sampling
• location and description of
• other relevant information,
sampling point(s)
documents, and/or pictures
• copies two most recent test results
Trihalomethanes, Turbidity and Other Testing Parameters:
• frequency of sampling
• location and description of
• other relevant information,
sampling point(s)
documents, and/or pictures
• copies two most recent test results
SECTION 7: CERTIFICATION
I certify that the information contained in this form and the attached information is complete and accurate to the best
of my knowledge.
Y Y Y Y
/
M M
/
D D
Signature of Owner __________________________________________________________
Date ___________________
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