APPLICATION FOR WATER SUPPLY SYSTEM CONSTRUCTION PERMIT
Water System Name: (Legal Name) Date:
Address: (if new) Postal Code:
Contact: Tel No:
E-mail:
Onsite Water System Owner: (Legal name if different: required for onsite works)
Corporate Address: Postal Code:
Onsite Contact: Tel No:
E-mail:
Description of proposed watermain extension/replacement (eg 200m of 150-mm PC235 PVC pipe):
Description of related works - source, treatment, reservoir, etc.
Is the existing Water system on a Boil Water Notice? Yes No
Does the submission include a new source(s)? Yes No
Does the water quality of the existing waterworks and/or new source(s) meet the
Drinking Water Protection Regulation and the Guidelines for Canadian Drinking Water Quality? Yes No
Will all watermains have 3 meters clear horizontal separation from sanitary and storm sewers? Yes No
At all crossings and wherever the normal horizontal separation is not possible are the Yes No
watermains at least 45 cm (18 inches) above and clear of the sanitary or storm sewer?
Have blow-offs or hydrants been provided for flushing purposes on all dead-ends and low points? Yes No
Have air relief valves, hydrants or services designed to provide air relief been provided at all high points? Yes No
Will watermains/reservoirs be disinfected per current AWWA standards? Yes No
Are all works on public right-of-ways or registered easements? Yes No
Are all plans, reports, specifications, etc., sealed and signed by a Professional Engineer? Yes No
How many new lots/connections will be serviced?
Is the capacity of the existing waterworks adequate (including existing and committed servicing)? Yes No
Are the lots serviced by septic tank or sewer system?
Is this plan: an initial submission or a revised submission
If applicable, has the local Approving Officer (or designated municipal approving officer) approved the subdivision? Yes No
This form is available online at: http://www.viha.ca/mho/environment/water_quality/drinking_water.htm
O:Water/Admin/app15
Signed:
Address:
Send to: Island Health – Public Health Eng.
3
rd
Floor – 6475 Metral Drive
Nanaimo BC V9T 2L9
Ph: 2250-755-6299 Fx: 250-755-3372
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