INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT
INSTRUCTIONS FOR COMPLETING THE
APPLICATION FOR CONSTRUCTION PERMITFOR PUBLIC WATER SYSTEM - 327 IAC 8-3-3
TYPE OR PRINT ALL ENTRIES
The following numbers refer to the enclosed application.
Enter the name of the Public Water System as they are chartered by the State of Indiana and check box if existing
or new public water supply system.
Enter the Public Water System Identification Number (PWSID) as chartered by the State of Indiana.
Enter the name and title of the Public Water System official.
Enter the telephone number of the Public Water System, including the area code.
Enter the address of the Public Water System.
Enter the fax number of the Public Water System.
Enter the name of the project.
Indicate the location of the project, which includes the city and reference to adjacent streets or roads.
Example: "Bowling Green (city), Madison Street, one block east of Eel River, north side of S.R. 46"
Enter the county(s) where construction will take place.
Indicate who is funding project.
Enter the name, title and address of the person who is to receive the permit, generally the person representing the
funding entity of the construction project (e.g., Developer, Superintendent, Utility Engineer)
Note: In accordance with 327 IAC 8-3-2, the permit shall be issued in the name of the person who causes
or allows construction, installation or modification of any facility, equipment, or device for any
public water supply.
Enter the telephone number and fax, including area code, of the person who is to receive the permit.
Enter the name of the local government official for Mayor, Town Board President, County Commissioner, if any.
Enter the address of the local government officials.
Enter the certification of the engineer.
The engineer responsible for the design of the project will put his/her signature, the date and his/her seal
[not just his/her Professional Engineer (P.E.) number] in the appropriate spaces. The engineer shall complete
Attachment A, B, C, D and E, as appropriate.
Note: The Engineer must be registered in the State of Indiana.
Print the name of the engineer.
Enter the date signed and the P.E. seal.
Enter the telephone number of the engineering firm, including the area code.
Enter the fax number of the engineering firm.
Enter the name and address of the firm mentioned in number 19, including street name and number, or Post Office
box number, city, state and ZIP code.