Commonwealth of Virginia
Department of Health Office of Drinking Water
Instructions: This form can be completed online, or a blank form can be printed to complete manually. If completing online, print, sign, and
date the form before mailing or faxing to the Office of Drinking Water Field Office in your region. Retain a copy of the completed form for
your records.
Permit type: Construction: New
Repair Modify Extend
(for ownership transfer of facilities already in existence)
Previous owner: Transfer date:
Waterworks name (if any):
State assigned PWS Identification Number (if any):
Water Source: Surface water
Groundwater: Well
Purchased (from another public waterworks for resale)
Name of wholesaling waterworks:
Proposed number of connections and type (residential, commercial, institutional):
Description of proposed work (for new construction):
I am associated, directly or indirectly, with the following waterworks in Virginia (name and PWS ID):
I am aware of needed local government approvals including zoning: YES
I am aware that permits may be needed for water withdrawal or waste discharge permits: YES
I have contacted the State Corporation Commission (community waterworks serving 50+ connections): YES
Please schedule a Conference for the week of , 20 .
Applicant Name (legal owner): Position/Title/Office:
I hereby certify that by signing and submitting this application to the Virginia Department of Health the subject water system
is or shall become a waterworks as defined by § 12 VAC 5-590-10 of the Virginia Waterworks Regulations, and as the
waterworks owner I shall comply with the Virginia Waterworks Regulations.
______________________________________ ____________
Applicant Signature Date
Waterworks Permit Application – Revised August 2007