Form 49008 - Notice Of Intent To Construct A Water Main Extension - Indiana Department Of Environmental Management Page 2

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Developer:

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

IAC 8-3.5. The construction of proposed project will meet all local rules 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."

Signature of developer

Date signed (month, day, year)

Public Water System:

"I certify under the penalty of law that I have agreed to furnish water to the area in which the water main is proposed. I acknowledge the public water system's

responsibility for examining the plans and specifications to determine that the proposed water main meet local rules or laws and ordinances. I also acknowledge

the public water system's responsibilities as outlined in 8-3.5-12. 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 PWS official

20. Project Design Criteria:

Alternative Technical Standards (327 IAC 8-3.2.20)

21. Are any "Alternative Technical Standards" proposed to be used in this project?

Yes, I have attached copies of the approval with the NOI.

Public Water System Capacity Status

MGD

22. The PWS's Daily Production Firm Capacity:

GPM

23. The PWS's five (5) highest demand days in the previous two (2) years: