Fillable PLAN REVIEW APPLICATION PROCESS NOTICE (Maricopa County Telecommunications)

Fill Online, Printable, Fillable, Blank PLAN REVIEW APPLICATION PROCESS NOTICE (Maricopa County Telecommunications) Form

Use Fill to complete blank online MARICOPA COUNTY TELECOMMUNICATIONS (AZ) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

PLAN REVIEW APPLICATION PROCESS NOTICE (Maricopa County Telecommunications)

On average this form takes 20 minutes to complete

The PLAN REVIEW APPLICATION PROCESS NOTICE (Maricopa County Telecommunications) form is 3 pages long and contains:

  • 0 signatures
  • 13 check-boxes
  • 74 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Maricopa County Telecommunications

BROWSE MARICOPA COUNTY TELECOMMUNICATIONS (AZ) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
NSA Existing Permit Application in fillable form; Process Notice (Page 1 Only) Page 1 of 3 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
PLAN REVIEW APPLICATION PROCESS NOTICE
New Drinking Water Source Approval
New Drinking Water Source Approval (NSA) is required for all drinking groundwater and surface water sources used by
Maricopa County regulated public water systems. For complete requirements for drinking water sources, please refer to
Arizona Administrative Code Title 18, Chapters 4 and 5. Copies are available from the office of the Arizona Secretary of
State or online at www.azsos.gov. This application must be completed by the PWS Permit Owner/Holder or authorized
representative of the public water system (PWS) and be submitted with the following required application documents:
o Water quality analyses results - All water quality analyses results must be collected at the raw water source no
greater than 12 month prior to application submission. All water quality analyses must be conducted by an
Arizona Dep
artment Health Services (ADHS) certified laboratory. All water quality analysis results mu
st be
subm
itted on the proper Arizona Department Environmental Qualit
y (ADEQ) Drinking Water Source Approval
reporting for
m
s.
o ADW
R Registration Record – A copy of the Arizona Department of Water Resources (ADWR) Registration
Record may be obtained from ADWR at www.azwater.gov or (602)771-8500.
o Well Driller’s Log - A copy of the Well Driller’s Log may be obtained from the person/business that drilled the
well or (ADWR) at ww
w.azwater.gov or (602)771-8500.
o Applicable scheduled plan review fee of $425.
Engineering Approval - Arizona law requires owners of water system components, including wells, treatment plants,
storage and pressure tanks, distribution mains, and booster pumps, to obtain approvals to construct (ATC) and approvals
of construction (AOC) prior to serving any drinking water source through a PWS. The PWS permit owner/holder or
authorized representative must complete and submit an ATC and AOC application for each drinking water system
component. Each ATC and AOC application must sealed by a Professional Engineer and submitted with required
scheduled plan review fees.
Please contact Cindy Furze at (602) 506-1058 for more information on engineering requirements for non-
treatment related water system components.
Please contact Dale Bodiya, P. E. at (602) 506-6670 for more information on engineering requirements for
treatment related water system components.
Plan Review
Process Steps:
1. Applicant submits complete New Source Approval Application with appropriate fee.
2. Department conducts review of application and onsite field inspection to determine approvability the drinking water
source.
3. Applicant provided with Department decision of “approval” or “disapproval” based on step 2.
The Department will approve or deny this application in 83 business days (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
NSA Existing Permit Application in fillable form Page 2 of 3 Revised December 2012
APPLICATION FOR
NEW
DRINKING WATER SOURCE APPROVAL
All fields are required to be completed. Incomplete applications will not be accepted.
Please Note: This application must be completed by the PWS Permit Owner or authorized representative of the PWS and submitted with
applicable water quality analyses results, ADWR Registration Record, Well Driller’s Log, and the applicable review fee.
Fee Enclosed (Please Check One): Standard Scheduled Fee - $425 Expedited Fee - $850 (Double Scheduled Fee)
Proposed Public Water System (PWS) Information
PWS Name : PWS 07
PWS Address:
Type of Public Water System: Community Non-transient Non-community Transient Non-community
Est. Population served: Est. # Service Connections: Approx. Start Date:
DWR Registration #: Water Source Type: Well CAP SRP Other:
Water Source Name: Existing EPDS New EPDS
Water Source Address: Water Source Designated EPDS:
PWS Permit Owner/Holder (PO) Information
PO Name: PO Contact Name:
Address: Zip Code:
Phone #: Fax #: Cell #: Email:
PWS Permit Billing (PB) Information
Billing Contact Name: Title:
Billing Address:
Phone #: Fax #: Cell #: Email:
PWS Primary
Certified Operator (CO) Information
Primary Certified Operator: License Number:
CO Business Name:
Address:
Phone #: Fax #: Cell #: Email:
Professional
Engineer (PE) Information
PE Name: License Number:
PE Business Name:
Address:
Phone #: Fax #: Cell #: Email:
Mail approval to:
Water System owner PWS Certified Operator Project Engineer
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
w
ith 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
NSA Existing Permit Application in fillable form Page 3 of 3 Revised December 2012
Letter of Authorization
Complete this form if the Permit Owner/Holder is not signing the attached application.
This form is effective 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.
Permit Own
er/Holder Signature:
Date:
Authorized Agent Signature:
Date:
Witness Name (Print)
Witness Signature
Date:
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

PLAN REVIEW APPLICATION PROCESS NOTICE (Maricopa County Telecommunications)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 6 August 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document