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New PWS Permit Application (TNCWS) 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 Transient Non-Community 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. A business, for example
a res
taurant or motel, that serves an average of at least 25 people per day but does not serve the same people for
more than six months of the year would be categorized as a transient non-community water system (TNCWS).
For complete requirements for public water systems, please refer to 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 major requirements must be complete prior to the issuance of a new TNCWS permit:
1. Capacity Development Approval. The Arizona Department of Environmental Quality (ADEQ)
reviews community systems’ financial and technical capacity. Systems must obtain this approval before
receiving an operating permit from Maricopa County. Please contact Linda Taunt of ADEQ at (602) 771-4416
for more information on this requirement.
2. New Source Approval. New Source Approval is required for both groundwater and surface water
sources. To obtain New Source Approval, the new TNCWS permit applicant must submit a New Source
Approval application, which includes a chemical analysis of all regulated contaminants in the source water; a
copy of the Department of Water Resources registration; and for a well, a well driller’s log and the scheduled
New Source Approval application review fee of $425.
3. Engineering Approval. Arizona law requires water system components, including wells, treatment
plants, storage and pressure tanks, 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
Professional Engineer with required scheduled review fees. Please contact Cindy Furze at (602) 506-1058 for
more information on engineering requirements.
4. Certified Operator. All public water systems must obtain the services of a certified water operator.
Operators monitor the water for various contaminants throughout the year, including bacteria, nitrate, nitrite,
lead, and copper. A certified operator must inspect each well site a minimum of once per month. 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.
5. MAP. Water systems that serve fewer than 10,000 people may be 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, nitrate, nitrite, lead, and copper. Please contact
Mary Kay Black of ADEQ at (602) 771-
4518
for more information, including program fees.
6. Operating Permit Issuance. After new TNCWS receives applicable approvals listed in requirements 1-
5 above, the applicant will be sent a Maricopa County public water system permit application and associated
invoice. Once the signed public water system permit application and appropriate scheduled annual permit fee is
received by the department, the operating permit will be issued to the permit owner/holder.
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@mail.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
New PWS Permit Application (TNCWS) in fillable form Page 2 of 4 Revised December 2012
APPLICATION FOR
NEW TRANSIENT NON-COMMUNITY PUBLIC WATER SYSTEM PERMIT
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. A
non-transient non-community water system (TNCWS) is defined as a system that does not regularly serve at least
25 of the same persons over six months per year. This application must be completed by the proposed public
water system permit owner/holder or authorized representative of the proposed public water system*.
Proposed P
ublic Water System (PWS) Information
PWS Name :
PWS Address:
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:
PW
S Permit Owner/Holder (PO) Information
PO Contact 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:
Profes
sional 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
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
New PWS Permit Application (TNCWS) 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 rows 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.
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
New PWS Permit Application (TNCWS) 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 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 Owner/Holder Signature:
Date:
Authorized Agent Signature:
Date:
Witness Name (Print)
Witness Signature
Date:
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Completed 6 August 2020

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