Form 583-B - Application For Permit To Construct Water Pollution Control

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Oklahoma Department of Environmental Quality
Check type(s) of
Construction Proposed
Water Quality Division | (405) 702-8100
707 N. Robinson , OKC, OK 73102-6010
Water Wells
P.O. Box 1677, OKC, OK 73101-1677
Waterlines
Water Treatment
Sanitary Sewer
Application for Permit to Construct Water Pollution Control
Wastewater Treatment
or Public Water Supply Facilities and/or Supply Potable Water
DEQ Form 583-B | July 2013
Water Reuse
A. Supply Potable Water:
Date: ______________ , 20 ___
B. Supply Reclaimed Water:
Date: ______________ , 20 ___
ONLY complete if construction is for potable water supply other than
ONLY complete if construction is for reclaimed water other than supplier
applicant
1. Supplier: _______________________________________
1. Applicant: _____________________________________
2. S-#: R: ________________________________________
2. PWS ID #: ______________________________________
3. Phone #: ______________________________________
3. Phone #: ______________________________________
4. Email: ________________________________________
4. Email: ________________________________________
5. User: _________________________________________
5. Purchaser: _____________________________________
6. Category: ______________________________________
(Attach Forms 627-WRP and 627 LAP if applicable)
C. Construction Facilities:
Date: ______________ , 20 ___
1. Applicant: __________________________________________________________________________________________________
2. S-# or PWSID #: ______________________________________________________________________________________________
3. Phone #: _______________________________ Email: _____________________________________________________________
4. Engineer’s: Email: ________________________ Phone #: ___________________________ Fax #: _________________________
5. Construction Proposal: ________________________________________________________________________________________
6. Serves: _____________________________________________________________________________________________________
7. Legal Description:
36
29
S
W
Okmulgee
Quarter ____/4 _____ /4 _____ /4 Section _______ Township ______ ____ Range _______ ____ County ________________________
26
29
36
S
26
W
Okmulgee
Quarter ____/4 _____ /4 _____ /4 Section _______ Township ______ ____ Range _______ ____ County ________________________
D. Fee: Enclosed is a check or money order (no cash) in the amount of $ ________. (Make checks and money orders payable to the
Oklahoma Department of Environmental Quality, Water Quality Division). If exempt from permit fees provide the Oklahoma Water
Resources Board REAP Grant No. _______________ and/or Emergency Grant No. _________________.
E. In making this application, the applicant certifies and states the following:
Yes
No
1.
The applicant has been supplied with copies of all rules and standards promulgated by the Oklahoma Department of
Environmental Quality for the construction and operation of the facility in question.
2. To the best of the knowledge and belief of the applicant the plans, specifications, and engineering report comply with
the requirements of the aforementioned rules and standards.
3.
The applicant agrees to provide inspection and be responsible for the construction and operation of the facility in accordance
with the aforementioned rules and standards, and in accordance with state law agrees that the Oklahoma Department of
Environmental Quality shall have access to the facility at any time during and after construction for the purpose of inspection
for compliance with the provisions of the Environmental Code, 27A O.S. § 2-1-101 and following et seq.
4. The applicant intends to own and operate the facility after construction is completed. If “No,” provide information on
responsibility for operation.
5. The applicant is holder of or will obtain a deed or easement to the land upon which construction is planned.
If “No,” explain. ____________________________________________________________________________________
6. The land upon which construction is planned is within the corporate limits of a municipality. If “Yes,” application should
be executed by authorized agent of the municipality. If “Yes” and applicant is other than a municipality, PRIVATE
APPLICANT WITHIN MUNICIPALITY section must be completed.
7. The wastewater is treated by an on-site sewage disposal systems. If “No,” the entity receiving, transporting, or treating
the wastewater generated by the area is the applicant. If “No,” the RECEIVE, TRANSPORT, OR TREAT section must be
completed for sanitary sewer projects.
8. All local zoning and other ordinances of public entities having jurisdiction concerning the construction of the proposed
improvements have been satisfied.
If “No” explain. ____________________________________________________________________________________

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