"Public Water System Screening Form" - Connecticut

Public Water System Screening 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 January 1, 2020;
  • The latest edition currently provided by the Connecticut State Department of Public Health;
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  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Public Health.

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Download "Public Water System Screening Form" - Connecticut

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STATE OF CONNECTICUT
DEPARTMENT OF PUBLIC HEALTH
PUBLIC WATER SYSTEM SCREENING FORM
Pursuant to CGS Sections 16-262m & 8-25a and RCSA Section 19-13-B102
Section 1: Basic Information
Conversion of Existing Structure/Property
Proposed Development
Project Type:
Unclassified Facility Currently in Operation
PWS Classification Review (Change in Use)
Change of Ownership (PWS Responsibilities letter will be sent out)
Anticipated Start Date:
Name of Facility
Maximum Daily Population Served
Customer of a
Current:
water company?
Yes
No
PWS ID #
Proposed:
Property Address
Number of Service
Number of days per
Proposed/current
Connections:
year facility is/will be
daycare capacity:
operational:
City
State
ZIP Code
Residential Non-Res
NA
Description of Project (Attach additional pages if necessary, please see instructions for additional information):
Section 2: Facility Information
Type of Facilities (Check all that apply)
Residential
School
Food Service
Day Care
Campground
Medical/Dental
Professional Office
Youth Camp
Gas Station
Retail
Manufacturing
Place of Worship
Park/Recreation Area
Other - specify:
Will or does the facility supply water for human consumption to its employees, students, customers, visitors and/or
members ?:
Yes
No
Type of water use at the facility (check all that apply):
drinking
bathing/showering
cooking
dishwashing
public restroom
drinking water fountain
____________________
other:
Will or do at least 25 persons (including employees, customers, parishioners, visitors, etc. but not necessarily the same
persons) visit the facilities/businesses supplied by the water system daily at least 60 days out of the year (days do not
need to be consecutive days)?
Yes
No
Facility annual operating period (begin/end dates of operation): From
(month/day) to
(month/day)
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:
Number of persons whose primary residence is or will be supplied by the facility based on design population:
Does this water system have any treatment?
Yes
No
If yes, specify type:
Purpose:
Section 3: Property Owner Contact Information
Name
Legal Contact Person (if owner is not an individual)
Mailing Address
City
State
ZIP Code
Telephone
Fax
Emergency Phone
E-mail Address
DPH-PWS-SCREEN
Page 1 of 2
Rev. 2020
STATE OF CONNECTICUT
DEPARTMENT OF PUBLIC HEALTH
PUBLIC WATER SYSTEM SCREENING FORM
Pursuant to CGS Sections 16-262m & 8-25a and RCSA Section 19-13-B102
Section 1: Basic Information
Conversion of Existing Structure/Property
Proposed Development
Project Type:
Unclassified Facility Currently in Operation
PWS Classification Review (Change in Use)
Change of Ownership (PWS Responsibilities letter will be sent out)
Anticipated Start Date:
Name of Facility
Maximum Daily Population Served
Customer of a
Current:
water company?
Yes
No
PWS ID #
Proposed:
Property Address
Number of Service
Number of days per
Proposed/current
Connections:
year facility is/will be
daycare capacity:
operational:
City
State
ZIP Code
Residential Non-Res
NA
Description of Project (Attach additional pages if necessary, please see instructions for additional information):
Section 2: Facility Information
Type of Facilities (Check all that apply)
Residential
School
Food Service
Day Care
Campground
Medical/Dental
Professional Office
Youth Camp
Gas Station
Retail
Manufacturing
Place of Worship
Park/Recreation Area
Other - specify:
Will or does the facility supply water for human consumption to its employees, students, customers, visitors and/or
members ?:
Yes
No
Type of water use at the facility (check all that apply):
drinking
bathing/showering
cooking
dishwashing
public restroom
drinking water fountain
____________________
other:
Will or do at least 25 persons (including employees, customers, parishioners, visitors, etc. but not necessarily the same
persons) visit the facilities/businesses supplied by the water system daily at least 60 days out of the year (days do not
need to be consecutive days)?
Yes
No
Facility annual operating period (begin/end dates of operation): From
(month/day) to
(month/day)
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:
Number of persons whose primary residence is or will be supplied by the facility based on design population:
Does this water system have any treatment?
Yes
No
If yes, specify type:
Purpose:
Section 3: Property Owner Contact Information
Name
Legal Contact Person (if owner is not an individual)
Mailing Address
City
State
ZIP Code
Telephone
Fax
Emergency Phone
E-mail Address
DPH-PWS-SCREEN
Page 1 of 2
Rev. 2020
Section 4: Certification Statement
I certify to the best of my knowledge that the information provided in this application is complete and correct. I
understand that the information I provide will be used by the Department of Public Health, Drinking Water Section to
determine if a proposed project or existing facility will be or is considered a water company and a public water system
and to also determine the most appropriate steps for initiating the regulatory process.
Signature of Property Owner/Legal Contact:
Date:
Printed Name of Property Owner/Legal Contact:
For Local Health Use Only
Section 5: Local Health Department Review
Please provide any additional information you believe would be helpful for DWS staff to evaluate this form. Examples of
additional information include any previous property names/ PWSID the water system may have been regulated under,
whether the property is part of a plaza with other uses and what those other uses might be, etc:
Local health understanding of water use at the facility:
drinking
bathing/showering
cooking
dishwashing
public restroom
drinking water fountain
____________________
other:
Is the information provided by the applicant in Section 1 and 2 of this form consistent with your understanding of the
current/proposed use of the property?
Yes
No
____________________________________________________
____________________
Signature of Local Director of Health or Registered Sanitarian
Date
_____________________________________________________
Printed Name of Local Director of Health or Registered Sanitarian
FOR DWS USE ONLY
CPCN:
Yes
No
Reactivation of former PWS:
Yes
No
New Water System (currently in operation):
Yes
No
PWS Classification Review:
Yes
No
Change of Ownership (send PWS responsibilities letter)
Yes
No
System Classification:
C
NTNC
TNC
NP Date of determination:
DWS Project #:
Please submit completed forms and all Supporting Documents to:
DWDCompliance@ct.gov
or
Department of Public Health
Drinking Water Section
410 Capitol Avenue, MS#12DWS
P.O. Box 340308
Hartford, CT 06134-0308
Save Form
Clear Form
Submit
DPH-PWS-SCREEN
Page 2 of 2
Rev. 2020
Page of 2