State Form 35058 - Application For Construction Permit For Public Water System - 327 Iac 8-3-3(A) - Indiana Department Of Environmental Management
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9APPLICATION FOR CONSTRUCTION PERMIT FOR
FOR AGENCY USE
PUBLIC WATER SYSTEM - 327 IAC 8-3-3(a)
Permit number
State Form 35058 (R5 / 9-98)
WS -
Approved by State Board of Accounts 1998
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
(
)
6. FAX number of PWS
5. Address of PWS
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 the funding entity
12. Telephone and FAX number of item 11.
of the construction project (i.e. Developer, Superintendent, Utility Engineer)
13. Name of local government official - Mayor:
Town Board or Council President
County Commissioner (if any)
14. Address of Local Government Official - Mayor
Address - Town Board or Council President
Address - County Commissioner
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.
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 firm
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 sealed by P.E.?
A. Is one complete set of legible plans submitted?
Yes
No
Yes
No
On IDEM file
C. Is each and every page of the plans signed and sealed by a professional engineer
D. Is a plan no more than 1 year old showing the sizes and locations of all mains in the
who is registered in the State of Indiana?
distribution system available? (If Yes, submit a copy)
Yes
No
Yes
No
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