Form 35058 - Application For Construction Permit For Public Water System And Instructions Page 3
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11APPLICATION FOR CONSTRUCTION PERMIT FOR
FOR AGENCY USE
PUBLIC WATER SYSTEM - 327 IAC 8-3-3
Permit number
WS -
State Form 35058 (R6 / 9-04)
Approved by State Board of Accounts, 2004
Indiana Department of Environmental Management
Drinking Water Branch
1. Name of Public Water System (PWS)
2. PWSID number
New
Existing
3. Name and title of PWS official (i.e. Superintendent, Utility Engineer/Manager)
4. Telephone number of PWS ((xxx) xxx-xxxx)
5. Address of PWS
6. FAX number of PWS ((xxx) xxx-xxxx)
7. Name of project
8. Location of project
9. County(s) of project
10. Source of funding for the project
PWS
Developer
Dept. of Commerce (DOC)
State Revolving Fund
Other
11. Name, title and address of the person who is to receive the permit, generally the person representing
12. Telephone number of person listed in item 11
the funding entity of the cobnstruction project (e.g., Developer, Superintendent, Utility Engineer)
((xxx) xxx-xxxx).
Fax number of item 11((xxx xxx-xxxx).
13. Name of local government official - Mayor
Town Board or Council President
County Commissioner (if any)
Address - County Commissioner
14. Address of Local Government Official - Mayor
Address - Town Board or Council President
15. Certification by Design Engineer
18. P.E. seal
I hereby certify that I am familiar with the information contained in this application and that to the
best of my knowledge and belief, such information is true, complete and accurate. I further certify
that construction of the proposed project following the application, plans and specifications will
produce drinking water of satisfactory quality in accordance with 327 IAC 8.
16. Signature of engineer
17. Printed name of engineer
19. Telephone number of engineering firm
20. FAX number of engineering firm
21. Name and address of engineering and developing firm, if applicable
Date signed (month, day, year)
FOR AGENCY USE
22. For water main construction: Complete Attachment A
Date received by IDEM (month, day, year)
23. For well construction: Complete Attachment B
24. For any pumping facility construction: Complete Attachment C
25. For storage facility construction: Complete Attachment D
26. For chemical addition: Complete Attachment E
27. For treatment facility construction: Complete all applicable Attachments
28. Plans and Specifications
B. Is a set of specifications submitted with the cover page signed and
A. Is one complete set of legible plans submitted?
Yes
No
sealed by P.E.?
Yes
No
On IDEM file
D. Is a plan no more than 1 year old showing the sizes and locations of all
C. Is each and every page of the plans signed and sealed by a
mains in the distribution system available? (If Yes, submit a copy)
professional engineer?
Yes
No
Yes
No
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