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Form 35058 - Application For Construction Permit For Public Water System And Instructions Page 2

22.

Check box if project contains water main construction: Complete Attachment A.

23.

Check box if project contains well construction: Complete Attachment B.

Check box if project contains pump construction: Complete Attachment C.

24.

25.

Check box if project contains storage facility construction: Complete Attachment D.

26.

Check box if project contains chemical addition construction: Complete Attachment E.

27.

Check box if project contains treatment facility construction: Complete all applicable Attachments.

28.

Check appropriate boxes to questions concerning plans and specifications.

29.

Check 327 IAC 8-3-7(a) to see if a processing fee is necessary. If so, check the appropriate box(es) and enclose a

check for the appropriate amount, made payable to: Indiana Department of Environmental Management.

30.

See example for address labels for a potentially affected person as defined by IC 4-21.5-3-5(b). If less than ten

(10) potentially affected parties, you must provide mailing labels for each potentially affected person. Also, a

Public Water System's official involved in this project should fill out the bottom section (No. 30) of the application. In

addition, if ten (10) or more potentially affected parties, IDEM will publish a public notice through the local

newspaper(s). As an option, you may indicate the name and address of the local newspaper(s) covering the area

where the construction project will take place.

Form 35058 - Application For Construction Permit For Public Water System And Instructions Page 2