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Maricopa

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Drinking Water New Source Approval Application

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All fields are required to be completed. Incomplete applications will not be accepted.

Please Note: This application must be completed by the PWS Permit Owner or authorized representative of the PWS and submitted with applicable water quality analyses results, ADWR Registration Record, Well Driller’s Log, and the applicable review fee.

Fee Enclosed

Type of Public Water System

Mail approval to

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

It is the responsibility of the permit holder to update the Department if there is a change in contact information

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.

I hereby authorize

of

to file a/an

application and act on my behalf during the application process.

Created by AIPSS