Form DEQ-2136 "Application for Approval of Engineering Plans and Specifications for Water Supply Systems" - North Carolina

What Is Form DEQ-2136?

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

Form Details:

  • Released on June 26, 2019;
  • The latest edition provided by the North Carolina Department of Environmental Quality;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DEQ-2136 by clicking the link below or browse more documents and templates provided by the North Carolina Department of Environmental Quality.

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Download Form DEQ-2136 "Application for Approval of Engineering Plans and Specifications for Water Supply Systems" - North Carolina

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North Carolina Department of Environmental Quality
Division of Water Resources
Public Water Supply Section
Application for Approval
of Engineering Plans and Specifications
For Water Supply Systems
Applicant
Design Engineer
(Name of Board, Council or Owner – the Applicant)
(Name of Design Engineer of Record)
(Name and Title of Authorized Official or Representative of the
(Name of Engineering Firm)
Applicant)
(Mailing Address)
(Mailing Address)
(City, State & ZIP)
(City, State & ZIP)
(Phone Number)
(Phone Number)
(FAX Number)
(FAX Number)
(Email address)
(Email address)
(Signature of Authorized Official or Representative of the
Applicant)
Project Name:
(Name of Project to appear on Public Water Supply Section records and tracking system)
(description of project)
(general location of project)
in
County.
Date
Serial No.
(for DEQ use only)
(for DEQ use only)
North Carolina Department of Environmental Quality
Division of Water Resources
Public Water Supply Section
Application for Approval
of Engineering Plans and Specifications
For Water Supply Systems
Applicant
Design Engineer
(Name of Board, Council or Owner – the Applicant)
(Name of Design Engineer of Record)
(Name and Title of Authorized Official or Representative of the
(Name of Engineering Firm)
Applicant)
(Mailing Address)
(Mailing Address)
(City, State & ZIP)
(City, State & ZIP)
(Phone Number)
(Phone Number)
(FAX Number)
(FAX Number)
(Email address)
(Email address)
(Signature of Authorized Official or Representative of the
Applicant)
Project Name:
(Name of Project to appear on Public Water Supply Section records and tracking system)
(description of project)
(general location of project)
in
County.
Date
Serial No.
(for DEQ use only)
(for DEQ use only)
Application for Approval of Engineering Plans and Specifications for Water Supply Systems
To:
Division of Water Resources,
Department of Environmental Quality
The Applicant applies under and in full accord with the provision of NCGS 130A-317, and such other statutes and rules as
relate to public water systems. The Authorized Official or Representative of the Applicant represents that he is authorized
to act for the Applicant. The Authorized Official or Representative of the Applicant understands and agrees to the
following:
1. The Applicant shall not award contracts or begin construction without first receiving “Authorization to Construct”
from DEQ.
2. The Applicant shall make no change or deviation from the engineering plans and specifications approved by DEQ
except as allowed by 15A NCAC 18C .0306 or with the written consent and approval of DEQ.
3. The Applicant shall obtain Final Approval in accordance with 15A NCAC 18C .0306 prior to placing the project (or
any portion thereof) into service.
4. Digital (PDF) submittals are true image copy of the original sealed/signed documents.
An authorized representative of the Public Water System (not always the same as the Applicant) is to complete and
sign the following WSMP section.
Status of Water System Management Plan (WSMP)
Check one of the following, and if applicable, provide the required information:
The WSMP for the project, as defined in the attached engineering plans and specifications, has not been submitted.
Three copies of the WSMP for the project, as defined in the attached engineering plans and specifications, are
submitted with this application.
The WSMP that includes this project, as defined in the attached engineering plans and specifications, was previously
submitted.
Provide the following:
Public Water System Name:
Owner Name:
NC
Water System No.:
Serial Number of Deemed Complete WSMP:
By my signature below, I certify that the previously submitted WSMP contains the information required by 15A
NCAC 18C .0307(c) for the project defined in the attached engineering plans and specifications.
(Type or print name of authorized representative of Public Water System)
(Title of authorized representative of Public Water System)
(Signature of authorized representative of Public Water System)
(Date)
DEQ-2136 (Revised 06/26/2019)
Page 2 of 4
Public Water Supply Section
Application for Approval of Engineering Plans and Specifications for Water Supply Systems
In accordance with NCGS 130A-328, the Public Water Supply Section charges a fee for plan review. Any
documents submitted for review must be accompanied by a check payable to DEQ-Public Water Supply
Section before the review will begin.
There is a $25 fee for returned checks.
The charges for review of plans are shown below. Check one of the following.
Distribution System fees
Construction of water lines, less than 5000 linear feet
$150
Construction of water lines, 5000 linear feet or more
$200
Other construction or alteration to a distribution system
$ 75
Ground Water System fees
Construction of a new ground water system or adding a new well
$200
Alteration to an existing ground water system
$100
Surface water system fees
Construction of a new surface water intake or treatment facility
$250
Alteration to existing surface water intake or treatment facility
$150
Other fees
Water System Management Plan review
$ 75
Miscellaneous changes or maintenance not covered above
$ 50
Notes:
1. Projects for Tank Rehabilitation use separate “Application for Water Tank Reconditioning Plan Approval.”
2. The fee is not refundable if the plans are not approved.
3. Revisions to plans to address the Public Water Supply Section’s or other state agency’s comments do not
incur an additional fee.
4. If one set of plans has multiple related items (such as a new well with construction of water lines) only one
fee must be submitted for highest price item. The amounts are not cumulative, except for fees for Water
System Management Plans.
5. If the appropriate plan review fee is not received within ten days after the receipt of plans,
specifications, and reports for approval, then all plan documents will be recycled. A new set of
documents must then be submitted with the appropriate fee for approval.
This approval does not address all applicable laws, rules, standards and criteria, and other approvals and licenses
that may be required by the local, state or federal government.
The Public Water Supply Section has stamped and sealed the official copies of plans and specifications
accompanying this application with the serial number of this application ____________________________. Any
erasures, additions or alterations of the proposed improvements except those permitted in 15A NCAC 18C .0306
make this approval null and void.
This approval does not constitute a warranty of the design, construction or future operation of the water system.
Signed: ____________________________________
Robert W. Midgette, P.E.
Chief, Public Water Supply Section
Division of Water Resources
DEQ-2136 (Revised 06/26/2019)
Page 3 of 4
Public Water Supply Section
Application for Approval of Engineering Plans and Specifications for Water Supply Systems
Other Information and Checklist Page
Attached is a check for the proper plan review fee amount, in accordance with NCGS 130A-328. See
note 4 on page 3.
This submittal includes one paper original with two digital (PDF) CDs of the following items, each item in separate
folders:
This completed “Application for Approval of Engineering Plans and Specifications for Water Supply
Systems”
The sealed plan drawings, separate file in PDF format for each drawing. Cover sheet must
;
include drawings index
The project-specific Engineering Report (ER) describing the scope and purpose of the project and
addressing each of the items listed in 15A NCAC 18C .0307(b), including the design basis of the project.
[15A NCAC 18C .0307(b) (12)];
Specifications for this project; OR
The project will use the following system’s previously approved standard specifications for waterline
extensions:
Name of System:
Serial Number:
The Serial Numbers for previously approved standard specifications can be found at the following website:
http://www.ncwater.org/?page=424
One of the following:
Attached is a letter signed by an authorized representative of the Public Water System agreeing to serve
the project and stating that the system has adequate supply;
OR
The Applicant is the Public Water System.
If the project has sought funding (for example, DWSRF loan) list the program and (if available) the application
or funding number below:
Program Name
Application or Funding Number, if
available
Yes
No
Project will be completed with significant expenditure of state moneys, greater than ten million
dollars ($10,000,000) in accordance with G.S. 113A-9 (7a).
Project will cause substantial, permanent land-disturbing activity of an area greater than 10 acres
of public lands in accordance with G.S. 113A-9 (11).
DEQ-2136 (Revised 06/26/2019)
Page 4 of 4
Public Water Supply Section