Fillable New Drinking Water Operating Permit for Existing Public (Maricopa County Telecommunications)

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New Drinking Water Operating Permit for Existing Public (Maricopa County Telecommunications)

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PWS Permit Application for Existing PWS in fillable form; Process Notice (Page 1 Only) Page 1 of 4 Revised December 2012
ENVIRONMENTAL SERVICES DEPARTMENT
Darcy Kober, R.S., Director
501 N. 44th St., Suite 200
Phoenix, AZ 85008
TT (602) 506-6704
WATER & WASTE MANAGEMENT DIVISION
Eric Matson, P.E., Division Manager
Kenyata Mangar, R.S., Drinking Water Program Manager
(602) 506-6935
FAX (602) 372
-
0866
PERMIT APPLICATION PROCESS NOTICE
New Drinking Water Operating Permit for Existing Public Water System
According to the Safe Drinking Water Act, any water system that supplies more than 25 people or 15 service connections
per day for at least 60 days per year is classified as a public water system (PWS). For complete requirements for public
water systems, please refer to the Arizona Administrative Code Title 18, Chapter 4. Copies are available from the office
of the Arizona Secretary of State or online at www.azsos.gov. The following requirements may need to be completed
prior to issuing a new permit for an existing PWS:
1. Drinking Water System Compliance Review. A Drinking
Water System Compliance Review (CR) must be
requested no
more than 30 days prior to submission of this application to determine the existing PWS permit’s comp
liance
status with all applicable PWS rules and regulations.
The CR request must be submitted with the current schedule fee
of
$250.
2. Certified Op
erator. All public water systems must obtain the services of a certified water operator. Operat
ors
m
onitor the water for various contaminants throughout the year, including
bacteria, nitrate, nitrite, lead, and copper. A
certified operator m
ust inspect each well site a minimum of once per month. If an employee or associate of the system
may wish to become certified, you may contact Noah Adams of ADEQ at (602) 771-4511 or
refer to the ADEQ web site
www.azdeq.gov for more information on operator certification.
3. New Source Approval. New Source Approval (NSA) is required for all water sources used by the PWS. Public
water systems will be required to obtain additional source approvals if the water source has been inactive for more than 12
consecutive months or suspected source contamination has occurred. Source Approval applications may require a
chemical analysis of some or all regulated contaminants in the source water in addition to a copy of the Arizona
Department of Water Resources registration for a well, a well driller’s log and the scheduled NSA applicat
ion review fee
of $42
5
.
4. Engineering Approval. Arizona law requires water sy
stem components, including well
s, treatment plants,
storage and pressure t
anks, distribution mains, and booster pumps, to obtain Approvals to Construct and Approvals of
Construction. The system must complete these applications and submit plans sealed by a Professiona
l Engineer with
required scheduled review fees. Please contact Cindy Furze at (602) 506-1058 for more information on engineering
requirements.
5. MAP. Community and Non-Transient, Non- community water systems that serve fewer than 10,000 people are
required to participate in ADEQ’s Monitoring Assistance Program (MAP). MAP performs much of the required sampling
for systems, but does not sample for bacteria, lead, copper or disinfection by products. Please contact Mary Kay Black of
ADEQ at (60
2) 771-4518 for more information, including program fees.
6. Operating Permit Issuance. After the existing PWS receives all applicable approvals listed in requiremen
ts 1-5
above, the applicant will b
e sent a Maricopa County PWS permit application and associated invoice. Once the signed
PWS permit application and appropriate scheduled annual permit fee is received by the department, the drinking water
operating permit will be issued to the perm
it owner/holder.
The Department will
approve or deny this application in 83 business day
s
(16 day - Administrative Review, 67 day -
Substantive Review) excluding any days the application is returned to the applicant for additional information. You may
request a clarification from the Department of its interpretation or application of a statute, ordinance, regulation,
delegation agreement or authorized substantive policy statement as provided in A.R.S. §11-1609. Contact us by e-mail,
regular mail, telephone, or in person at the address listed at the top of the page, marked attention Drinking Water Program
(DWP). The DWP Application Clerk is the contact for information regarding this application and can be reached at
(602)506-6935 or sdwquestions@Maricopa.gov with any questions. Additional application information may also be
found on our program website at http://www.maricopa.gov/2350/Drinking-Water.
Maricopa County Environmental Services Department
For Internal Use Only
CAP ID DW- Staff Assigned
PWS Permit Application for Existing PWS in fillable form Page 2 of 4 Revised December 2012
APPLICATION FOR
NEW DRINKING WATER OPERATING PERMIT FOR EXISTING PUBLIC WATER SYSTEM
All fields are required to be completed. Incomplete applications will not be accepted.
Please Note: According to the Safe Drinking Water Act (SDWA), any water system that supplies more than 25
people or 15 service connections per day for at least 60 days per year is classified as a public water system. This
application must be completed by the new public water system permit owner/holder or authorized representative.
A Drinking Water System Compliance Review must be requested no more than 30 days prior to submission of
this application to determine the existing PWS permits compliance status with all applicable public water system
rules and regulations.
Existing Per
mitted Public Water System (PWS) Information
PWS Name:
PWS Address:
PWS ID#: 07- Type of PWS: Community
Non-transient
Transient
# of Treatment Plants:
Est. Population served: Est. # Service Connections:
Water Source Type:
(Check all that apply)
: Well CAP SRP Other: # of Wells:
N
ew Public Water System Permit Information
PWS Name:
PWS Address:
Type of PWS: Community
Non-transient Transient # of Treatment Plants:
Est. Population served: Est. # Service Connections:
Water Source Type:
(Check all that apply)
: Well CAP SRP Other: # of Wells:
PW
S Permit Owner/Holder (PO) Information
PO Name: PO Contact Name:
Address:
Phone #: Fax #: Cell #: Email:
PW
S Permit Billing (PB) Information
Billing Contact Name: Title:
Billing Address:
Phone #: Fax #: Cell #: Email:
PW
S Primary Certified Operator (CO) Information
Primary Certified Operator: License Number:
CO Business Name:
Address:
Phone #: Fax #: Cell #: Email:
Mail approval to:
Water System owner PWS Certified Operator
Pursuant to A.R.S. § 41-1009, the Department may enter your establishment to conduct inspections. You have the right to receive a
copy of the Department’s inspection report at the time of the inspection, within thirty (30) days after the inspection, or as otherwise
provided by federal law. By initialing below, I agree that the Department may send me a copy of its inspection report by e-mail to the
following email address: or by facsimile transmission to the following fax number : .
(Permit Owner/Holder initials) .
It is the responsibility of the permit holder to update the Department if there is a change in contact information.
PWS Permit Owner/ Holder*:
(Person
with Fiduciary Responsibility) Name (Print) Signature Date
(*Attached Letter of Authorization required if application is not signed by Permit Owner/Holder)
Maricopa County Environmental Services Department
For Internal Use Only
CAP ID DW- Staff Assigned
PWS Permit Application for Existing PWS in fillable form Page 3 of 4 Revised December 2012
Public Water System Inventory Form
Instructions: Provide a comprehensive list of all public water system (PWS) sites and each component located
at each PWS site. Insert additional rows or pages as needed for additional PWS sites and components located
at each PWS site.
Public Water System Name :
Public Water System Address:
PWS ID #: 07- Type of PWS: Community
Non-Transient
Transient
Sample List
Site Address: 1234 E. Main, Anycity, AZ 85000
Site Status: x Active
Inactive Proposed Abandoned Unknown
Component Type: Component ID: Component Description/Component Name
x Water Source(s): 55-121212 Well head
x Water Source(s): U11122 Surface Water Intake
x Treatment Plant: TPGW001 Ground Water Treatment: Arsenic Treatment Facility
x Treatment Plant: TPSW001 Surface Water Treatment Plant: Traditional
x Water Storage: 3A-ES2E 100,000 gal Reservoir / SHAW BUTTE RESERVOIR - EAST
x Booster Station: 9A-B1 Number of Pumps: 5 / WELL #280 BOOSTERS
x Disinfection: CL-001 Chlorine, liquid
Comments: This is a sample listing of components you may have in your PWS.
Actual PWS Inventory
Site Address 1:
Site Status: Active Inactive Proposed Abandoned Unknown
Component
Type:
Component ID: Component Description/Component Name
Water Source(s):
Treatment Plant:
Water Storage:
Booster Station:
Disinfection:
Comments:
Site Address 2:
Site Status: Active Inactive Proposed Abandoned Unknown
Component
Type:
Component ID: Component Description/Component Name
Water Source(s):
Treatment Plant:
Water Storage:
Booster Station:
Disinfection:
Comments:
The undersigned person is affirming that the inventory information provided for this PWS is accurately reported to the best of his/her
knowledge on the date of application submittal and understands that the PWS Permit Owner/Holder is required to notify the Department
if the public water system inventory changes.
PW
S Permit Owner/Holder*:
(Person with Fiduciary Responsibility) Name (Print
) Signature Date
(*Attached Letter of Authorization required if application is not signed by Permit Owner/Holder)
Maricopa County Environmental Services Department
For Internal Use Only
CAP ID DW- Staff Assigned
PWS Permit Application for Existing PWS in fillable form Page 4 of 4 Revised December 2012
Letter of Authorization
Complete this form if the Permit Owner/Holder is not signing the attached application.
This form is effectiv
e for one (1) year from the date of Permit Owner/Holder signature.
All fields are required. Incomplete applications will not be accepted.
Permit Information
Permit Name:
Permit #:
Permit Type:
Permit Address:
Permit Owner/Holder (PO) Information
PO Name:
PO Address:
Phone #: Fax #:
Cell #: Email:
Authorized Agent (AA) Information
AA Name:
AA Firm Name:
Address:
Phone #:
Fax #:
Cell #: Email:
I hereby authorize of
(firm name)
to file a/an application
and act on my behalf during the application process.
Perm
it Owner/Holder Signature:
Date:
Authorized Agent
Signature:
Date:
Witness Na
me (Print)
Witness Signature
Date:
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Completed 6 August 2020

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