Watershed or Aquifer Area Project Notification Form
REQUIREMENT:
Within seven days of filing, all applicants before a municipal Zoning Commission, Planning and Zoning Commission,
Zoning Board of Appeals or Inland Wetlands Commission for any project located within a public water supply aquifer or
watershed area are reguired by Public Act No. 06-53 of the CT General Statutes to notify The Commissioner of Public
Health and the project area Water Company of the proposed project by providing the following information.
To determine if your project falls within a public water supply aquifer or watershed area visit the appropriate town hall
and look at their Public Drinking Water Source Protection Areas map. If your project falls completely within or contain
any part of a public water supply aquifer or watershed you are required to complete the following information.
Note: You will need information obtained from the Public Drinking Water Source Protection Areas map located
in the appropriate town hall to complete this form.
Step 1: Have you already notified the CT Department of Public Health (CTDPH) of this project?
No, Go to Step 2
Yes, I have notified DPH under a different project name - Complete steps 4-6
Yes, same name different year - Notification Year Complete steps 4-6
Step 2:
1. Name of public water supply aquifer your project lies within:
2. Name of the public water supply watershed your project lies within:
3. Public Water Supply Identification number (PWSID) for the water utility:
CT
Step 3: For 1-5 Check all that apply
1. My project is proposing:
Industrial use; Commercial use; Agricultural use; Residential use;
Recreational use; Transportation improvements; Institutional (school, hospital, nursing home, etc.);
Quarry/Mining; Zone Change, Please Describe:
Other, Please describe:
2. The total acreage of my project is:
Less than or equal to 5 acres Greater than 5 acres
3. My project site contains, abuts or is within 50 feet of a:
Wetland; Stream; River; Pond or Lake
4. Existing use of my project site is:
Grassland/meadow; Forested; Agricultural; Transportation; Institutional (school, hospital,
nursing home, etc.); Residential; Commercial; Industrial; Recreational; Quarry/Mining
Other Please Describe:
5. My project will utilize:
septic system; existing public sewer; new public sewer; agricultural waste facility;
existing private well; new private well; existing public water supply;
new public water supply, if new have you applied for a certificate of public convenience and necessity from
DPH? Yes No
6. My project will contain this percentage of built up area (buildings, parking, road/driveway, pool): Less than
or equal to 20% Greater than 20% to 50% Greater than 50%
Step: 4 Applicants Contact Information:
Name:
E-mail address:
Telephone:
Fax number:
Step 5: Please provide the following if available:
Project name:
Project site address:
Town:
Project site nearest intersection:
Project site latitude and longitude:
E-mail completed form to dph.swpmail@ct.gov
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