Hea 5237 - Job Status / Completion - Pond Water Supply

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Ohio Department of Health
JOB STATUS / COMPLETION FORM
POND WATER SUPPLY
PERMIT INFORMATION (
must be completed when submitting for the Job Status or the Completion Form portions)
Private water systems contractor
Registration number
Phone #
Address of property
County
Permit #
JOB STATUS
The job status portion is used to document the stages of completion for the private water system. The job status form must be
completed and submitted in person, by fax, or by email to the local health district within ten (10) business days of completion of the
portion of work completed by the private water systems contractor noted above. This job status form is required according to Ohio
Administrative Code Rule 3701-28-03 (O) effective April 1, 2011.
Date you completed this portion of the work
Briefly list all work completed - (Examples: “Developed spring and Installed spring box” and ”)
COMPLETION FORM -
Record all information of work completed
The completion form portion documents the specific materials, placement, and installation methods used to complete the work. This
form must be completed and returned to the local health district prior to final approval of the private water system. This completion form
is required according to Ohio Revised Code 3701.34, 3701.44 and Ohio Administrative Code 3701-28-03(P), and must be submitted
within thirty (30) days of completion of work.
Does the completed pond conform to the submitted plans?
YES
NO
If checked “YES”, explain all changes:
Construction Details
Pond Surface Area Size
Depth of Deepest portion
Approximate Watershed Size
Acreage
Feet / inches
Acreage
Are drainage swales or ditches being used to ensure owner control of watershed?
Yes
No
Intake
Flotation device intake
Submersible pump with cased pond intake
Location of intake
Intake Depth
inches
Backflow Prevention Devices
ASSE
1013
1015
1024
Backflow Protection Devices installed:
Filters
Slow Sand
Pressurized Rapid Sand
Pre-coat
Other (must be approved by ODH): ___________________________
Other Water Components
Continuous Disinfection is required for all Ponds used to supply water as a private water system. The
completion form for Continuous Disinfection Units must be submitted with this completion form.
HEA 5237 (Rev 03/2011)

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