HomeMy WebLinkAboutNOI Water Main Extension
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INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT
INSTRUCTIONS FOR COMPLETING THE FORM
FOR NOTICE OF INTENT TO CONSTRUCT A WATER MAIN EXTENSION - 327 IAC 8-3.5-4
TYPE OR PRINT ALL ENTRIES.
The following numbers refer to the enclosed form.
1. Enter the title of the proposed project (i.e. Meadow Brook Subdivision – Phase 2).
2. Enter the county(s) where the water main extension construction will take place.
3. Indicate the location of the project, which includes the city and reference to adjacent streets or roads.
4. Enter the name, title, e-mail address and affiliated business name of the responsible person as defined in 327 IAC
8-3.5-6.
5. Enter the telephone number of the responsible person listed in box 4.
6. Enter the address of the responsible person listed in box 4.
7. Enter the name of the public water system providing water service to the water main extension.
8. Enter the Public Water System Identification Number (PWSID) as chartered by the State of Indiana.
9. Enter the address of the public water system listed in box 7.
10. Enter the telephone number of the public water system listed in box 7.
11. Enter the name of the professional engineer and his/her firm name designing this water main extension.
12. Enter the telephone number of the professional engineer listed in box 11.
13. Enter the address and e-mail address of the professional engineer listed in box 11.
14. Enter the name and e-mail address of the developer (if applicable) for the water main extension.
15. Enter the telephone number of the developer (if applicable) listed in box 14.
16. Enter the address of the developer (if applicable) listed in box 14.
17. Check the applicable box for “timing of construction” for the water main extension. For the first check box option,
you must enter a start date and an approximate completion date. For the second check box option, you must
provide written notification within at least ten (10) working days before construction begins. NOTE: For both
options, construction cannot begin less than thirty (30) days after IDEM receives a complete and sufficient
NOI application. IDEM receipt date will be either e-mail receipt when submitted via the NOI dedicated e-mail
address (dwnoi@idem.in.gov) or certified mail receipt.
Example: "Bowling Green (city), Madison Street, one block east of Eel River, along State Road 46"
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18. Check 327 IAC 8-3-7(a) to see if a processing fee is required. Exempt organizations are both a governmental entity
and one of the listed categories. If you are not a governmental entity, then you are not exempt from the
construction permit processing fee. If you are unsure, contact the Permits Section via e-mail at dwnoi@idem.in.gov
or by calling (317) 234-7421, prior to submitting the NOI form. If a processing fee is required, payment must be
submitted using one of the following methods:
A. Make check/money order payable to IDEM (Acct.#3240-414000-140000) and mail with a copy of the
completed first page of the NOI form to:
IDEM
PO Box 3295
Indianapolis, IN 46206-3295
B. Remit by ACH to:
ABA#: 071921891
Bank Account Number: 4620695315
Bank Account Name: State of Indiana
AND send a copy of the first page of the completed NOI form, amount of payment and payment date to
water@idem.in.gov.
C. To pay by credit card, call (317) 234-3099 and leave the information requested in the telephone message
and e-mail copy of the first page of the completed NOI, the amount of payment and payment date to
water@idem.in.gov.
19. All applicable certifications must be signed and dated. For all water main extensions, there must be a responsible
person, professional engineer and public water system official. The developer certification may or may not be
applicable. If a person fills more than one certification role, they must sign and date each applicable
certification section.
20. Check the appropriate box. Design and construction must follow all technical standards for water main
extensions found in 327 IAC 8-3.2. Alternate technical standards are not allowed under an NOI, unless the
alternate technical standard has already been approved for this water system by the commissioner in
accordance with 327 IAC 8-3.2-20. A copy of this alternative technical standard approval must be submitted with
the NOI form.
21. Enter the public water system’s daily production firm capacity (see 327 IAC 8-3.3-3) in million gallons per day
(MGD) in box A and gallons per minute (GPM) in box B.
22. Enter the public water system’s five (5) highest demand days and volumes in the previous two (2) years only.
NOTE: the volumes must be in million gallons per day (MGD). The public water system will need to review
their demand numbers for the current year, previous year and the year before to determine the five (5) highest
demand dates and volumes. For example, if the NOI form was being submitted on August 1, 2014, then the five
(5) highest days would be sometime within January 1, 2012 – July 31, 2014. Any other days and volumes prior
to that date range would not be acceptable.
23. Calculate and enter into box C the average of five highest demand days listed in box 22.
24. Divide box C number by box A number, and then multiply by 100. Enter the calculated percent into box D.
25E. Enter the number of residential homes being provided water by this water main extension into box E. If this water
main extension is not adding any new residential homes/customers due to it being a water main replacement
only, or if it is only adding commercial and/or industrial customers, then enter 0 into box E.
25F. Enter the Peak Daily Demand Factor, calculated in accordance with 327 IAC 8-3.3-2, into box F. For residential
homes, this number must be at least 0.87 gallons per minute/home.
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25G. Multiply box E number and box F number and enter result into box G.
25H. For commercial and industrial customers being added as a result of the water main extension, provide a
description of each including size of meter and safe maximum operating capacity of the meter. If fire protection is
being provided, include appropriate fire flow demand. NOTE: For commercial and industrial customer demand
see Table 2-1 in 327 IAC 8-3.3-2(b).
25I. Add box G and box H and enter result into box I.
25J. Divide box I by box B, then multiply by 100. Enter the calculated percent into box J.
26A. Check the appropriate box. If no commercial or industrial customers are being added, check “N/A”. In accordance
with 327 IAC 8-10-4(c) the following facilities are designated as cross connection hazards:
1. Aircraft and missile manufacturing plants;
2. Automotive plants, including those plants that manufacture motorcycles, automobiles, trucks, recreational
vehicles, and construction and agricultural equipment;
3. Beverage bottling plants, including dairies and breweries;
4. Canneries, packing houses, and reduction plants;
5. Car washes;
6. Chemical, biological, and radiological laboratories, including those in high schools, trade schools, colleges,
universities, and research institutions;
7. Hospitals, clinics, medical buildings, autopsy facilities, morgues, other medical facilities, and mortuaries;
8. Metal and plastic manufacturing, fabricating, cleaning, plating, and processing facilities;
9. Plants manufacturing paper and paper products;
10. Plants manufacturing, refining, compounding, or processing fertilizer, film, herbicides, natural or synthetic
rubber, pesticides, petroleum or petroleum products, pharmaceuticals, radiological materials, or any chemical
that could be a contaminant to the public water supply;
11. Commercial facilities that use herbicides, pesticides, fertilizers, or any chemical that could be a contaminant
to the public water supply;
12. Plants processing, blending, or refining animal, vegetable, or mineral oils;
13. Commercial laundries and dye works, excluding coin-operated laundromats;
14. Sewage, storm water, and industrial waste treatment plants and pumping stations;
15. Waterfront facilities, including piers, docks, marinas, and shipyards;
16. Industrial facilities that recycle water; and,
17. Restricted or classified facilities (federal government defense or military installations), or other facilities closed
to the supplier of water or to the commissioner.
26B. Check the appropriate box. In accordance with 327 IAC 8-10-4, an air gap must be constructed or a reduced
pressure principal backflow preventer shall be installed on the customer service line to any facility that is
designated as a cross connection control hazard (see list above).
If you have any questions on filling out this form, or if your project will qualify for an NOI, please e-mail your question(s)
to dwnoi@idem.in.gov or contact the Drinking Water Branch at (317) 234-7421.
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NOTICE OF INTENT TO CONSTRUCT A WATER MAIN EXTENSION
State Form 49008 (R3 / 4-15)
Approved by State Board of Accounts, 2015
General Construction Permit For Water Main Extensions
1. Title of proposed project
2. County of proposed project
3. Location of proposed project (including nearest public intersection and nearest quarter Section, Township, Range)
4. Name, title, e-mail address and firm of responsible person (as defined in 327 IAC 8-3.5-6)
5. Telephone number of responsible person
( )
6. Address of responsible person (number and street, city, state, and ZIP code)
7. Name of Public Water System (PWS)
8. PWS identification number
9. Address of PWS (number and street, city, state, and ZIP code)
10. Telephone number of PWS
( )
11. Name and firm of professional engineer
12. Telephone number of professional engineer
( )
13. Address (number and street, city, state, and ZIP code) and e-mail address of professional engineer
14. Name and e-mail address of developer (If applicable) 15. Telephone number of developer
( )
16. Address of developer (number and street, city, state, and ZIP code)
17. Timing of construction (check one of the following):
The proposed construction of the water main will begin on and be completed on . (Cannot begin construction less than thirty (30)
days after IDEM receives a complete and sufficient NOI.)
The proposed construction schedule will be submitted separate from this NOI at least ten (10) working days before the commencement of the construction
and will include a copy of the information on the first page of this NOI. (Cannot begin construction less than thirty (30) days after IDEM receives a
complete and sufficient NOI.)
18. Fee Schedule:
No fee, exempted under 327 IAC 8-3-7(a).
No fee for water main extensions under 2,500 linear feet.
$150 for water main extensions from 2,501 to 5,000 linear feet.
$250 for water main extensions from 5001 to 10,000 linear feet.
$500 for water main extensions greater than 10,000 linear feet.
The complete NOI form may be submitted by e-mail (dwnoi@idem.in.gov) or by certified mail to the
address below.
Indiana Department of Environmental Management
Drinking Water Permits Section (IGCN Rm 1201)
100 North Senate Avenue
Indianapolis, IN 46204
If a fee is required, see instructions for payment options.
19. Certifications:
Responsible Person:
"I certify that I have reviewed and understand the applicability and eligibility requirements of this rule and that the water main proposed with the submission of
this NOI meets the applicability and eligibility requirements of this rule. I also certify that the design and construction of this project will be performed under my
direction or supervision to assure conformance with 327 IAC 8-3.5 and will meet all local rules or laws, regulations and ordinances. The information submitted is,
to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the
possibility of fine and imprisonment.
Signature of responsible person Date signed (month, day,year)
Professional Engineer:
"I certify under the penalty of law that the design of this project will be performed under my direction or supervision to assure conformance with 327 IAC 8-
3.5 and that the plans and specification will require the construction of said project to be performed in conformance with this rule. The design of the
proposed project will meet all local rules or law, regulations and ordinances. The information submitted is, to the best of my knowledge and belief, true,
accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment."
Signature of professional engineer Date signed (month, day,year)
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Developer:
"I certify under the penalty of law that the construction of this project will be performed under my direction or supervision to assure conformance with 327 IAC
8-3.5. The construction of proposed project will meet all local rules or laws, regulations and ordinances. The information submitted is, to the best of my
knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of
fine and imprisonment."
Signature of developer Date signed (month, day,year)
PWS Representative:
"I certify under the penalty of law that I have agreed to furnish water to the area in which the water main is proposed. I acknowledge the public water system's
responsibility for examining the plans and specifications to determine that the proposed water main meet local rules or laws and ordinances.
I also acknowledge the public water system's responsibilities as outlined in 327 IAC 8-3.5-12. I am aware that there are significant penalties for submitting false
information, including the possibility of fine and imprisonment."
Signature of PWS representative Date signed (month, day,year)
Project Design Criteria:
Alternative Technical Standards (327 IAC 8-3.2-20)
20. Are any "Alternative Technical Standards" proposed to be used in this project?
Yes, I have attached copies of the approval with the NOI. No
Public Water System Capacity Status
21. The PWS's Daily Production Firm Capacity: A. MGD B. GPM
22. The PWS's five (5) highest demand days in the previous two (2) years only:
Demand (MGD) Date (month, day, year)
1.
2.
3.
4.
5.
23. Average of five (5) Peak Daily Demand (PDD) listed above: C. MGD
24. Ratio of PDD to PWS Daily Production Capacity = (Item D = Item C / Item A x 100) D. %
25. Anticipated Customer Demand of Proposed Water Main
Residential Customers:
E. Number of homes
F. Average Daily Demand times Peaking Factor (at least 0.87
gpm/home)
G. Total Average Daily Demand times Peaking Factor (G = E x F)
gpm
Other (Commercial and Industrial) Customers:
Description (including size of domestic meter): Average Daily Demand (the "Safe Maximum
Operating Capacity" of domestic meter)
gpm
gpm
Sub Total: H. gpm
Total Customer Demand of Proposed Water Main (gpm) = (Item G + item H) I. gpm
Ratio of total Customer Demand of Proposed Water Main (gpm) to the PWS Daily Production Firm
Capacity (gpm) (Item J = Item I/ Item B x 100) J. %
26. Cross Connection Hazard Prevention
A. Are any of the new customers included in Section 25 designated as cross connection hazards (see instructions)? Yes No N/A
B. Will an air gap be constructed or a reduced pressure principal backflow preventer be installed on the customer’s service line? Yes No N/A