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New PWS Permit Application (NTNCWS) 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 Non-Transient Non-Community Public Water System
According to the Safe Drinking Water Act, any water system that supplies more than 25 peopl
e 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
(NTNCWS) is defined as a system that serves the same 25 or more persons for at least six months per year. For example, a
business with 25 or more employees would likely be classified as a NTNC. 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 NTNCWS 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 grou
ndwater and surface water sources. To
obtain New Source Approv
al, the new NTNCWS 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 $42
5
.
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 oper
ator 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.a
zdeq.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
Assist
ance Program (MAP). MAP performs much of the required sampling for systems, but does not sample for bacteria
,
nitrate, nitrit
e, lead, and copper. Please contact Mary Kay Black of ADEQ at (602) 771-4518 for more informatio
n,
includin
g program
fees.
6. Operating P
ermit Issuance. After new NTNCWS 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 th
e
signed public
water system permit application and appropriate scheduled annual permit fee is received by the departme
nt,
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 (NTNCWS) in fillable form Page 2 of 4 Revised December 2012
APPLICATION FOR
NEW NON-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 (NTNCWS) is defined as a system that serves the same 25 or more
persons for at least 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 Public 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:
PWS Permit Owner/Holder (PO) Information
PO Name: PO Contact Name:
Address:
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 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 (NTNCWS) 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 (NTNCWS) 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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