Form DEEP-WPMD-REQ-001 "Request for Reauthorization Under the General Permit for Diversion of Water for Consumptive Use" - Connecticut

What Is Form DEEP-WPMD-REQ-001?

This is a legal form that was released by the Connecticut Department of Energy and Environmental Protection - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 17, 2017;
  • The latest edition provided by the Connecticut Department of Energy and Environmental Protection;
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Download Form DEEP-WPMD-REQ-001 "Request for Reauthorization Under the General Permit for Diversion of Water for Consumptive Use" - Connecticut

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Request for Reauthorization under the General Permit for
Diversion of Water for Consumptive Use
Notice to Requesters:
This form is only for those currently authorized
CPPU USE ONLY
under the following General Permits:
 General Permit for Diversion of Water for Consumptive Use: Authorization
App #:________________________________
Required Categories (DEP-IWRD-GP-012) issued March 29, 2007;
 General Permit for Diversion of Water for Consumptive Use: Filing Only
Categories (DEP-IWRD-GP-011) issued March 15, 2007;
Doc #:________________________________
 General Permit for Diversion of Water for Consumptive Use:
Reauthorization Categories (DEP-IWRD-GP-01R) issued March 15, 2007.
Check #:______________________________
In order to use this form, the quantities requested in Part VI, # 2 of this
form must be equal to or less than previously approved quantities. Any
______________________________________
increase of such quantities will result in the rejection of your request,
Program:
whereby your activity may be eligible for authorization under other
GP IWRD Diversion for Consumptive Use
consumptive diversion general permits or through an “individual” water
diversion permit.
Please complete this form in accordance with the
instructions
(DEEP-WPMD-INST-001) to ensure the proper handling of your
request for reauthorization. Print or type unless otherwise noted. You must submit the total fee with this form.
Those not currently authorized as such and seeking coverage under the General Permit for Diversion of Water for
Consumptive Use must complete Form DEEP-WPMD-REQ-002 or DEEP-WPMD-REQ-003 depending on their eligibility
category.
Notice to Municipal Agencies: This is a request for reauthorization submitted to the Department of Energy and
Environmental Protection (DEEP) pursuant to CGS section(s) 22a-6 and 22a-378a. For any questions, call DEEP’s Water
Planning and Management Division at 860-424-3704.
Part I: Existing Authorization
1.
Application/Authorization Number:
Issue Date:
If applicable, include, as Attachment A, a copy of your current approval under the General Permit for Diversion of
Water for Consumptive Use: Authorization Required Categories (DEP-IWRD-GP-012) expiring March 29, 2017.
2.
Town where site is located:
3.
Brief Description of Authorized Diversion:
DEEP-WPMD-REQ-001
Page 1 of 7
Rev. 01/17/17
Request for Reauthorization under the General Permit for
Diversion of Water for Consumptive Use
Notice to Requesters:
This form is only for those currently authorized
CPPU USE ONLY
under the following General Permits:
 General Permit for Diversion of Water for Consumptive Use: Authorization
App #:________________________________
Required Categories (DEP-IWRD-GP-012) issued March 29, 2007;
 General Permit for Diversion of Water for Consumptive Use: Filing Only
Categories (DEP-IWRD-GP-011) issued March 15, 2007;
Doc #:________________________________
 General Permit for Diversion of Water for Consumptive Use:
Reauthorization Categories (DEP-IWRD-GP-01R) issued March 15, 2007.
Check #:______________________________
In order to use this form, the quantities requested in Part VI, # 2 of this
form must be equal to or less than previously approved quantities. Any
______________________________________
increase of such quantities will result in the rejection of your request,
Program:
whereby your activity may be eligible for authorization under other
GP IWRD Diversion for Consumptive Use
consumptive diversion general permits or through an “individual” water
diversion permit.
Please complete this form in accordance with the
instructions
(DEEP-WPMD-INST-001) to ensure the proper handling of your
request for reauthorization. Print or type unless otherwise noted. You must submit the total fee with this form.
Those not currently authorized as such and seeking coverage under the General Permit for Diversion of Water for
Consumptive Use must complete Form DEEP-WPMD-REQ-002 or DEEP-WPMD-REQ-003 depending on their eligibility
category.
Notice to Municipal Agencies: This is a request for reauthorization submitted to the Department of Energy and
Environmental Protection (DEEP) pursuant to CGS section(s) 22a-6 and 22a-378a. For any questions, call DEEP’s Water
Planning and Management Division at 860-424-3704.
Part I: Existing Authorization
1.
Application/Authorization Number:
Issue Date:
If applicable, include, as Attachment A, a copy of your current approval under the General Permit for Diversion of
Water for Consumptive Use: Authorization Required Categories (DEP-IWRD-GP-012) expiring March 29, 2017.
2.
Town where site is located:
3.
Brief Description of Authorized Diversion:
DEEP-WPMD-REQ-001
Page 1 of 7
Rev. 01/17/17
Part II: Eligible Diversion Activity Type and Fee Information
Check the appropriate box to indicate the activity that is the subject of this request for reauthorization. Please complete one
Request for Reauthorization for each current authorization you wish to reauthorize. For municipalities, a 50% discount
applies. The request for reauthorization will not be processed without the fee. The fee shall be non-refundable and shall be
paid by check or money order to the Department of Energy and Environmental Protection or by such other method as the
commissioner may allow.
Subject Activity
Fee
[1082]
Interconnection and Transfer of up to 1,000,000 gpd
$2500.00
Withdrawal of up to 250,000 gpd – Surface Water / Stratified Drift Aquifer
$2500.00
Withdrawal of up to 250,000 gpd – Bedrock Aquifer
$2500.00
Backup Wells
$2500.00
Small Supplemental Bedrock Well
$2500.00
Small Water Supply System
$2500.00
Large Tidally-Influenced Rivers
$2500.00
Water Supply System Interconnection
$2500.00
Unregistered Water Supply Systems
$2500.00
Diversion of up to 250,000 gallons per day New Water
$2500.00
Restoration of Lost Capacity
$2500.00
Part III: Requester Information
If a requestor is a corporation, limited liability company, limited partnership, limited liability partnership, or a statutory
trust, it must be registered with the Secretary of State. If applicable, requestor’s name shall be stated exactly as it is
registered with the Secretary of State. This information can be accessed at CONCORD.
If a requestor is an individual, provide the legal name (include suffix) in the following format: First Name; Middle Initial;
Last Name; Suffix (Jr, Sr., II, III, etc.).
If there are any changes or corrections to your company/facility or individual name, mailing or billing address or contact
information, please complete and submit the
Request to Change Company/Individual Information
to the address indicated on
the form. For any other changes you must contact the specific program from which you hold a current DEEP license. If there
is a change in ownership, please contact the Permit Assistance Office for questions concerning license transfers at 860-424-
3003.
1.
Applicant/Requestor
Name:
Mailing Address:
City/Town:
State:
Zip Code:
Business Phone:
ext.:
Contact Person:
Phone:
ext.
*E-mail:
*By providing this e-mail address you are agreeing to receive official correspondence from the department, at this electronic address,
concerning the subject registration. Please remember to check your security settings to be sure you can receive e-mails from “ct.gov”
addresses. Also, please notify the department if your e-mail address changes.
a)
Requestor Type (check one):
individual
*business entity
federal agency
state agency
municipality
tribal
*If a business entity:
i)
check type:
corporation
limited liability company
limited partnership
limited liability partnership
statutory trust
Other:
ii)
provide Secretary of the State business ID #:
This information can be accessed at
CONCORD
iii)
Check here if you are NOT registered with the SOTS.
Check here if any co-requestors. If so, attach additional sheet(s) with the required information as requested above.
DEEP-WPMD-REQ-001
Page 2 of 7
Rev. 01/17/17
Part III: Requester Information (continued)
b)
Requestor's interest in property at which the proposed activity is to be located:
site owner
option holder
lessee
easement holder
operator
other (specify):
2.
Billing contact, if different than the requestor.
Name:
Mailing Address:
City/Town:
State:
Zip Code:
Business Phone:
ext.:
Contact Person:
Phone:
ext.
*E-mail:
3.
Primary contact for departmental correspondence and inquiries, if different than the requestor.
Name:
Mailing Address:
City/Town:
State:
Zip Code:
Business Phone:
ext.:
Contact Person:
Phone:
ext.
*E-mail:
4.
Attorney or other representative, if applicable.
Firm Name:
Mailing Address:
City/Town:
State:
Zip Code:
Business Phone:
ext.:
Attorney:
Phone:
ext.
*E-mail:
5.
Owner of the property, if different than the requestor.
Name:
Mailing Address:
City/Town:
State:
Zip Code:
Business Phone:
ext.:
Contact Person:
Phone:
ext.
*E-mail:
6.
Owner of the facility, if different than the requestor.
Name:
Mailing Address:
City/Town:
State:
Zip Code:
Business Phone:
ext.:
Contact Person:
Phone:
ext.
*E-mail:
DEEP-WPMD-REQ-001
Page 3 of 7
Rev. 01/17/17
Part III: Requester Information (continued)
7.
Consultant(s) employed or retained to assist in preparing the request for authorization or in designing or
constructing the activity.
Check here if additional sheets are necessary, and label and attach them to this sheet.
Name:
Mailing Address:
City/Town:
State:
Zip Code:
Business Phone:
ext.:
Contact Person:
Phone:
ext.
*E-mail:
Service Provided:
Part IV: Compliance and Enforcement History
Complete and include an Applicant Compliance Information Form (DEEP-APP-002) as Attachment B.
Have all requirements of your current authorization been met including special conditions, record keeping and reporting
requirements?
Yes
No
If no, explain:
Note: Failure to meet requirements of your current authorization or a significant violation of environmental law
may result in a denial of your request.
Part V: Site Information
Site Name and Location
Name of Site(s) :
Street Address or Location Description:
City/Town:
State:
Zip Code:
DEEP-WPMD-REQ-001
Page 4 of 7
Rev. 01/17/17
Part VI: Project Summary
1. Regulated Activity
Describe the diversion, which is the subject of this request for reauthorization including the reason for the
diversion and the present use of the water diverted.
Check if additional sheets are attached to this page.
2. Quantity, Rate, Frequency and Duration of Diversion
Note: All quantity, rate, frequency and duration figures entered below must be equal to or less than
previously approved quantities under the General Permit for which you are currently authorized.
Name of diversion structure(s)
Maximum daily withdrawal (mg)
(i.e. the largest volume of water to be withdrawn in
any 24 hour period)
Maximum rate of withdrawal (cfs)
Average day-maximum month withdrawal (mgd)
Frequency of withdrawals
hours/day
days/year
If the withdrawal is seasonal provide dates diversion
will be used:
Part VII: Supporting Documents
Please check the box by the attachments being submitted as verification that all applicable attachments have been submitted
with this Request for Reauthorization form. When submitting any supporting documents, label the documents as indicated in
this part (e.g., Attachment D, Location Map, etc.) and be sure to include the requester's name as indicated on this application
form. Note that in addition to the supporting documents described in previous sections, your request for reauthorization must
include a location map as Attachment D.
Attachment A:
Existing Authorization: If applicable, include, a copy of your current approval under the General
Permit for Diversion of Water for Consumptive Use: Authorization Required Categories (DEP-
IWRD-GP-012) issued March 29, 2007.
Attachment B:
Compliance and Enforcement History: a completed copy of the
Applicant Compliance Information
Form
(DEEP-APP-002).
Location Map: an 8.5” X 11” copy of the relevant portion of the most recent version of the United
Attachment C:
States Geological Survey topographic map at a (scale of 1:24,000) depicting the location of the
subject withdrawal(s) and, if possible, the property boundaries wherein the subject withdrawal
occurs.
Attachment D:
Additional Information: Include in this attachment any additional information not specifically
requested which may assist the department in determining compliance with this general permit.
DEEP-WPMD-REQ-001
Page 5 of 7
Rev. 01/17/17
Page of 7