3900-PM-BSDW0002
Instructions
Rev. 8/2013
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF SAFE DRINKING WATER
Please remove and recycle these instructions prior
to mailing to the approving agency.
INSTRUCTIONS FOR COMPLETING AND SUBMITTING
PUBLIC WATER SUPPLY PERMIT APPLICATION
GENERAL INSTRUCTIONS
The following instructions are designed to assist the applicant in completing the Public Water Supply Permit
Application. The Public Water Supply Permit Application is to be completed in conjunction with the appropriate
modules and the Department-wide General Information Permit Application, and must be accompanied by a design
engineer’s report and appropriate plans and specifications. Perhaps the most important document in a public
water supply permit application is the design engineer’s report. The engineer’s report ties the application
together, provides the technical basis of design and explains how the system is proposed to operate. Each permit
application should be able to “stand on its own” and the engineer’s report is the primary document that accomplishes
this. It is far more than a place to include calculations and report sample results.
SECTION A – APPLICANT IDENTIFIER
Applicants must provide the full name that would be used on official documents by the water system.
SECTION B – PROJECT INVENTORY
The initial question refers to the above-named water system providing water to the public for human consumption.
Human consumption includes the activities of drinking, bathing, showering, cooking, dishwashing, and maintaining
oral hygiene. This question is to be answered “yes” for bottled and vended water systems, retail water facilities, or
bulk water hauling systems.
Proposed Activity – Applicant must specify what type of activity or activities the project will involve. Modification
implies alteration to an existing permitted system.
Proposed Source Type – Applicant must specify what type of water source or sources the project will use. If
available, the name of the source should be provided.
Proposed Facilities – Applicant must specify what type of facility or facilities the project will include. If the project
involves a facility that is not included on the application list, it should be specified in the space identified as “Other”.
SECTION C – CERTIFICATION AND SIGNATURES
Responsible Official – The water system person responsible for completing this permit application must provide
his/her name, title, and postal mailing address, and must sign and date the application.
AFFIDAVIT – The completed permit application must be notarized by a notary public.
Design Engineer – The engineer responsible for designing the project must be registered as a professional engineer
(P.E.) in the state of Pennsylvania. The engineer must provide his/her name, employer or employment name, postal
mailing address, and daytime telephone number. The design engineer must also sign and date the application, as
well as affix his/her embossed P.E. seal to the permit application in the space provided.
FEE – A permit fee payable to the “Commonwealth of Pennsylvania” must accompany the application. The
amount of the fee may vary according to the proposed activities, and can be obtained from either DEP regulations in
Chapter 109, or from the appropriate DEP regional office.
The applicant should be aware of the possibility of interaction with local or county health departments, depending on
the health department and the type of water system facilities. Regional DEP staff can refer the applicant to the
appropriate health department.
WHERE TO FILE
The completed application should be sent to the DEP regional office or county health department having jurisdiction
in your area. A listing of regional office addresses and phone numbers are listed on the back page.
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3900-PM-BSDW0002
Instructions
Rev. 8/2013
For more information,
call the DEP regional office in your area or contact:
Department of Environmental Protection
Bureau of Safe Drinking Water
Division of Planning and Conservation
P.O. Box 8467
Harrisburg, PA 17105-8467
Fax: (717) 772-5630
(717) 772-4048
DEP REGIONAL OFFICES
Southeast Region
2 E. Main Street
Norristown, PA 19401-4915
Water Supply: 484-250-5980
Wastewater: 484-250-5970
Southwest Region
400 Waterfront Drive
Pittsburgh, PA 15222-4745
Water Supply: 412-442-4217
Wastewater: 412-442-4038
Southcentral Region
909 Elmerton Ave.
Harrisburg, PA 17110
Water Supply: 717-705-4708
Wastewater:
717-705-4707
Counties: Bucks, Chester,
Delaware, Montgomery and
Philadelphia
Counties: Allegheny, Armstrong,
Beaver, Cambria, Fayette, Greene,
Indiana, Somerset, Washington
and Westmoreland
Counties: Adams, Bedford, Berks, Blair,
Cumberland, Dauphin, Franklin, Fulton,
Huntingdon, Juniata, Lancaster, Lebanon,
Mifflin, Perry and York
Northwest Region
230 Chestnut St.
Meadville, PA 16335-3481
Water Supply: 814-332-6899
Wastewater:
814-332-6942
Northeast Region
2 Public Square
Wilkes-Barre, PA 18701-1915
Water Supply: 570-826-2511
Wastewater:
570-826-2554
Northcentral Region
208 W. Third St., Suite 101
Williamsport, PA 17701
Water Supply: 570-327-3490
Wastewater:
570-327-3670
Counties: Butler, Clarion, Crawford,
Elk, Erie, Forest, Jefferson,
Lawrence, McKean, Mercer, Venango
and Warren
Counties: Carbon, Lackawanna,
Lehigh, Luzerne, Monroe,
Northampton, Pike, Schuylkill,
Susquehanna, Wayne and
Wyoming
Counties: Bradford, Cameron, Centre,
Clearfield, Clinton, Columbia, Lycoming,
Montour, Northumberland, Potter, Snyder,
Sullivan, Tioga and Union
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3900-PM-BSDW0002
Application
Rev. 8/2013
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF SAFE DRINKING WATER
DEP USE ONLY
DATE RECEIVED
PUBLIC WATER SUPPLY PERMIT APPLICATION
Before completing this form, read the step-by-step instructions provided in the Public Water Supply Permit Application
Instructions.
SECTION A. APPLICANT IDENTIFIER
Applicant Name:
SECTION B. PROJECT INVENTORY
Will the water system serve at least 15 service connections or an average of at least 25 individuals at least 60 days out
of the year?
Yes
No
Proposed Activity
Proposed Source Type
Construction
Well(s)
Lake(s)
Modification
Spring(s)
Stream(s)
Finished Source
Source Name
Proposed Facilities
BVRB Systems
Impoundment
Corrosion Control for lead/copper
Bottled Water System
Settling
Disinfection
Vended Water System
Filtration
Pump Station(s)
Retail Water Facility
Iron and Manganese Treatment
Transmission Lines
Bulk Water Hauling System
Softening
Finished Water Storage
Fluoridation
Bulk Water Loading Station(s)
Distribution Facility
Other
General Corrosion Control
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3900-PM-BSDW0002
Application
Rev. 8/2013
SECTION C. CERTIFICATION AND SIGNATURES
I hereby certify that the completeness report and all plans, modules, and documents designated therein are attached
to this application, and made a part hereof.
Signature of Responsible Official
Name of Responsible Official
Title of Responsible Official
Date of Application
Address
AFFIDAVIT
Commonwealth of Pennsylvania/State of
.
(Circle one) County of
I,
, being duly sworn, according to law, depose and say that I (am
the applicant) (am an officer or official of the applicant) (have the authority to make this application) and that the plans,
reports and documents submitted as part of the application are true and correct to the best of my knowledge and
belief.
Sworn and Subscribed to before me this
Day of
, 20
.
Signature of Responsible Official
Notary Seal
Notary Public
Name of Design Engineer
Name of Firm
Address
Telephone Number
Signature of Design Engineer
Date
Design Engineer’s Seal
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