Form 49008 - Notice Of Intent To Construct A Water Main Extension - Indiana Department Of Environmental Management

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NOTICE OF INTENT TO CONSTRUCT A WATER MAIN EXTENSION

State Form 49008 (9-98)

Approved by State Board of Accounts, 1998

General Construction Permit For Water Main Extensions

2. County of project

1. Title of project

3. Location of project (including nearest public intersection and nearest quarter Section, Township, Range)

4. Name of responsible person, title, firm

5. Telephone number

6. Address of firm

7. Public Water System (PWS)

8. PWS ID

9. Address of PWS

10. Telephone number of PWS

11. Name of engineering firm

12. Telephone number of engineering firm

13. Address of engineering firm

14. Name of developer

15. Telephone number of developer

16. Address of developer

17. Timing of construction (check one of the following):

The proposed construction of the water main will begin on _________________________________________________________ and be completed

on______________________________________ . (Cannot begin construction less than thirty (30) days after IDEM received the NOI.)

The proposed construction schedule will be submitted separate from this NOI at least ten (10) working days before the commencement of the construction

and will include a copy of the information on the first page of this NOI. (Cannot begin construction less than thirty (30) days after IDEM received the

NOI.)

18. Fee Schedule:

THE COMPLETE NOTICE OF INTENT ALONG WITH ALL REQUIRED FEES

MUST BE SUBMITTED BY CERTIFIED MAIL TO:

No fee, exempted under 327 IAC 8-3-7(a).

DRINKING WATER BRANCH

No fee for water main extensions under 2,500 linear feet.

Indiana Department of Environmental Management

$150 for water main extensions from 2,501 to 5,000 linear feet.

100 North Senate Avenue

$250 for water main extensions from 5001 to 10,000 linear feet.

P.O. Box 6015

Indianapolis, Indiana 46206-6015

$500 for water main extensions greater than 10,000 linear feet.

Make checks payable to: I.D.E.M. (Acct.# 3240-414000-140000)

19. Certifications:

Responsible Person:

"I certify that I have reviewed and understand the applicability and eligibility requirements of this rule and that the water main proposed with the submission

of this NOI meets the applicability and eligibility requirements of this rule. I also certify that the design and construction of this project will be performed under

my direction or supervision to assure conformance with 327 IAC 8-3.5 and will meet all local rues or laws, regulations and ordinances. The information submitted

is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including

the possibility of fine and imprisonment.

Date signed (month, day, year)

Signature of responsible person

Engineer:

"I certify under the penalty of law that the design of this project will be performed under my direction or supervision to assure conformance with 327 IAC 8-

3.5 and that the plans and specification will require the construction of said project to be performed in conformance with this rule. The design of the proposed

project will meet all local rules or law, regulations and ordinances. The information submitted is, to the best of my knowledge and belief, true, accurate, and

complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment."

Date signed (month, day, year)

Signature of engineer

(Continued on the reverse side.)