Form No. 626-Mr-Sc-Px - Application For Municipal Or Rural Waterline Extension
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1Check Type of
Oklahoma Department of Environmental Quality
Connection
Water Quality Division | Phone: 405-702-8100
Construction Permitting Section
Rural Multiple
707 N. Robinson, OKC, OK 73102-6010
Rural Single
P.O. Box 1677, OKC, OK 73101-1677
Municipal Multiple
Municipal Single
Application for Municipal or Rural Waterline Extension
Construction Permit Exemption
Application
Date _____________________, 20_______
1.
Applicant: _______________________________________________________________________________________________
2.
PWSID#: _________________________________________________________________________________________________
3.
Proposed construction will serve: ____________________________________________________________________________
4.
Legal Description: ___ /4, ___ /4, ___ /4, of Section ______, T- ___ - ___, R - ___ - ___, I.M. / C. M., _____________________ County
Include a plan drawing showing location of proposed waterline (plan drawing is required to obtain a permit exemption).
Diameter of the existing supply line is _______________ inches.
Diameter of proposed waterline extension is _______________inches.
Minimum pressure at point of connection to the existing supply waterline is _______________ psi.
Minimum pressure in the proposed waterline extension, based on elevation change, is _______________ psi.
Length of proposed waterline extension is _______________ feet.
In making this application the applicant certifies and states the following:
•
The applicant has been supplied with copies of all rules and standards promulgated by the Oklahoma Environmental Quality Board
for the construction and operation of the proposed waterline extension.
•
To the best of the knowledge and belief of the applicant, the existing waterline has not been extended previously pursuant to this
permit exemption provision.
•
The design and construction of the proposed waterline extension meets or exceeds Board standards.
•
If a municipality, after completion of the construction, but prior to the commencement of service by such extension, the applicant will
submit to the Department a sufficiency certification form 626-M-SC by a Professional Engineer registered in the State of Oklahoma.
•
If a rural, after completion of the construction, but prior to the commencement of service by such extension, the applicant will submit
to the Department a sufficiency certification form 626-SC-SC by a certified waterworks operator licensed by the State of Oklahoma.
Applicant Signature
Note:
Application must be signed by the authorized chief elective or executive officer of the applicant. Information must be legible.
_________________________________________________________
Signature
_________________________________________________________
Name of Authorized Signature
_________________________________________________________
Title
_________________________________________________________
Name of Organization
_________________________________________________________
Mailing Address
_________________________________________________________
Notary Public/Corporate Secretary/City Clerk
NOTARY SEAL
DEQ Form No. 626-MR-SC-PX
July 2013
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Parent category: Legal