Public Water Supply Permit Application Package {50103}

INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM PUBLIC WATER SUPPLY PERMIT APPLICATION PACKAGE Included in this package is a NPDES Public Water Supply Permit Application Form, an Instruction Sheet, a Fee Information Sheet and a Potentially Affected Persons Form. Please complete all requested information and return it to the address indicated on the Application Form. PUBLIC WATER SUPPLY APPLICATION COMPLETENESS CHECKLIST The following information must be included as part of the NPDES permit application: Completed, signed and dated Application Form Fifty dollar ($50) Permit Application Fee Potentially Affected Persons List Topographic map indicating outfall location(s) American LegalNet, Inc. www.FormsWorkflow.com PUBLIC WATER SUPPLY NPDES PERMIT APPLICATION INSTRUCTION SHEET 1. Name of Authorized Public Water Supply Official: Enter the name of the Mayor, Director of Utilities, Plant Superintendent, ranking elected official or other legally responsible person. Name of Public Water Supply: Give the facility's official or legal name. Mailing Address: Give the complete mailing address of the office where correspondence should be sent. Name of Primary Contact Person: Enter the name of a person who is familiar with the operation of the facility and with the facts reported in this application and who can be contacted by the IDEM if necessary. Phone Number: Give the phone number of the office where the contact person may be reached. E-mail Address: Give the e-mail address of the contact person (Optional). Facility Address: Give the address or location of the facility. If the facility lacks a street name or route number, give the most accurate alternative geographic information (e.g., section number or quarter section number from county records or at intersection of Rts. 425 and 22). Phone Number: Give the phone number of the facility. E-mail Address: Provide an e-mail address through which the facility can be contacted (Optional). Permit Status: Indicate whether the application is for a new facility, or for the renewal of an existing permit. If the application is for a permit renewal, indicate whether a modification to the existing permit is requested. NPDES Permit Number: Provide the NPDES Permit Number of the source (if a permit renewal or modification). Identification and Location of Outfalls: Identify each discharge point by outfall number (e.g., Outfall 001, Outfall 002) and give the name of the stream receiving the facility's discharge. If the receiving stream is an unnamed ditch, swale or field tile, then also list the first named water body into which the receiving stream flows. Also identify the County and the latitude and longitude (or U.S. Geological Survey Quadrangle name, section, range, and township) where the discharge enters the receiving stream. Include a topographic map with each outfall clearly marked. Use a supplemental sheet to list additional outfall(s). Source of Intake Water: Indicate the source of the treated water for each outfall identified in #12. Source of Wastewater: Indicate those components that contribute to the discharge of wastewater to surface waters. Do not list chemicals or treatment that are added or occur which are not discharged with the wastewater. Other Chemical Treatments: List all other chemical treatments that may be discharged. Contaminants in Intake Water: Indicate if you have any reason to believe pesticides or other contaminants are present in the intake water. In the space provided, please list the contaminants that you believe are present in the intake water. Treatment: Give a brief narrative description of any treatment that the backwash water undergoes prior to its discharge (i.e. sedimentation). Volume of Discharge: Give the average and maximum flow of the daily discharge in gallons per day. If the application is for a new facility, give an estimate of the volume of discharge. Signature: The application form must be signed by a person legally responsible for the facility. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. American LegalNet, Inc. www.FormsWorkflow.com National Pollutant Discharge Elimination System: PUBLIC WATER SUPPLY PERMIT APPLICATION State Form 50103 (R / 10-04) Indiana Dept. of Environmental Management Office of Water Quality - NPDES Permits Section 100 N. Senate Avenue Indianapolis, IN 46204 Phone: (317) 232-8603 or 1-800-451-6027 (Indiana Residents Only) http://www.in.gov/idem/water/permits/applications.html Form Approved by State Board of Accounts, 2004 INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT NOTE: This form is part of a NPDES public water supply permit application package; the following must be included as part of the NPDES permit application: - A completed, signed, dated application form (this form), - $50 permit application fee, - potentially affected persons list, - and a topographic map indicating outfall location(s). PART A: GENERAL INFORMATION 1. Name of authorized public water supply official: 2. Name of public water supply: 3. Mailing address: City: State: ZIP Code: CONTACT PERSON 4. Name of primary contact person: 5. Phone number ((xxx)) xxx-xxxx: 6. E-mail address (optional): FACILITY 7. Facility address: City State: ZIP Code: County: 8. Phone number ((xxx)) xxx-xxxx: 9. E-mail address (optional): PERMIT APPLICATION STATUS 10. Permit type (check one): New Renewal Modification 11. NPDES Permit Number (if facility has an existing permit): PART B: FACILITY INFORMATION 12. Identification and location of outfalls (include a topographic map showing location of outfall(s)): a. Outfall No.Receiving stream: Latitude: Longitude: County: b. Outfall No.Receiving stream: Latitude: Longitude: County: 13. Source of intake water (check each source for each outfall identified in #12): Outfall No. a. Outfall No.b. Outfall No.Well Well Source Surface stream Surface stream Lake Lake (Continued on page 2) Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com PART B: FACILITY INFORMATION (continued) 14. Source of wastewater (check all that apply) # a. b. c. d. e. f. g. h. Source of wastewater Filter Backwash Zeolite Softener Waste Lime Softener Waste Floor Drains Sedimentation Basin Waste Carbon Filtration Total Residual Chlorine Flocculent(s) Used ? Type of Flocculent(s): Outfall No.- Outfall No.- 15. List all other chemical treatments used that may be discharged: 16. Do you have any reason to believe pesticides or other contaminants are present