Form 35058 - Application For Construction Permit For Public Water System And Instructions Page 5
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11APPLICATION FOR CONSTRUCTION PERMIT FOR
Attachment A
PUBLIC WATER SYSTEM - 327 IAC 8-3-3
Water Main Construction
State Form 35058 (R6 / 9-04)
Approved by State Board of Accounts, 2004
Indiana Department of Environmental Management
Drinking Water Branch
1. Water Main Construction
A. This construction is (check all that apply)
New
Replacement
Relocation
B. Water Main Description
Diameter
Material Type
Class
Pressure Rating
Length
Types of Joints
Total Length =
C. Depth of cover per frost penetration table under IAC 8-3.2-17(d)
D. Is the proposed main providing fire protection?
inches
Yes
No
E. Will the main be pressure/leak tested per American Water Works Association (AWWA) C600-99?
Yes
No
If No, please attach a detailed description of the pressure/leak testing method.
Yes
No If No, please attach a detailed description of the disinfection method.
F. Will the main be disinfected per AWWA, C651-99?
G. Will fire hydrants and water mains at each tee, bend, and dead end be blocked or anchored per AWWA, C600-99?
Yes
No
If No, please attach a detailed description of the method.
2. Design Specifics and Plans
B. Minimum vertical clearance between water mains and sewers
A. Minimum horizontal clearance between water mains and sewers
(including storm drain) shall be 18 inches (ref. 327 IAC 8-3.2-9)
(including storm drains) shall be 10 feet (ref. 327 IAC 8-3.2-9).
Yes
No
Yes
No
C. Are there any stream crossings?
D. What is the maximum spacing between valves? E. What is the maximum spacing between hydrants?
Yes
No
F. Is there a history of external corrosion problems with buried pipe in the project area?
Yes
No
If Yes, provide copy of any corrosion study and explain corrosion protection measures.
3. System Design Data
C. Number of service connections to be served by
B. Number of existing service connections served by
A. System's total plant capacity: (Not firm capacity)
Public Water System
the proposed water main extension
GPD
D. Demand of Water Main Extension
gpm
1. Fire Flow
2. Unit Peak Daily Demand (per new customer)
gpm
3. Total Peak Daily Demand with Fire Flow of new water main extension [(Unit Peak Daily Demand x number
gpm
of customers) + fire flow]
psi
E. Pressure at the "Total Peak Daily Demand, No Fire Flow" flow rate at the point of connection
F. Pressure at the "Total Peak Daily Demand with Fire Flow" flow rate at the point of connection
psi
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