State Form 35058 - Application For Construction Permit For Public Water System - 327 Iac 8-3-3(A) - Indiana Department Of Environmental Management Page 5

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7. Certification to Furnish Water (this section must be completed)
The ________________________________________________________________________________________________ has agreed to furnish
City, Town, Village, Water Company or Water Authority
water to the area in which water main extensions are proposed by __________________________________________________________________
Name the person representing the funding entity of the construction project (i.e. developer)
according to plans titled "__________________________________________________________________________________" and prepared by
_______________________________________________________________________________ . The undersigned acknowledges the public
Name of Engineering Firm
water supplier's responsibility for examining the plans and specifications to determine that the porposed extensions meet local rules or laws,
regulations and ordinances.
Date signed (month, day, year)
By: (signature of public water system official)
Name of public water system
Title
Page 3

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