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

Standard Scheduled Fee - $425

Expedited Fee - $850 (Double Scheduled Fee)

PWS Name *

PWS 07_____ *

PWS Address *

Type of Public Water System

Community

Non-transient Non-community

Transient Non-community

Est. Population served *

Est. # Service Connections *

DWR Registration # *

Water Source Address *

Existing EPDS

New EPDS

Water Source Address *

Water Source Designated EPDS *

PO Name *

PO Contact Name *

Address *

Zip Code *

Phone *

Fax # *

Cell # *

Email *

Billing Contact Name *

Title *

Address *

Zip Code *

Phone *

Fax # *

Cell # *

Email *

Primary Certified Operator *

License Number *

CO Business Name *

Address *

Phone *

Fax # *

Cell # *

Email *

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

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.

Permit Name

Permit #

Permit Type

Permit Address

PO Name *

Address

Phone *

Fax #

Cell #

Email *

AA Name

AA Firm Name

Address

Phone *

Fax #

Cell #

Email *

I hereby authorize

Name

Firm name

to file a/an

name

application and act on my behalf during the application process.

Created by AIPSS

Maricopa

Drinking Water New Source Approval Application

Fees

Proposed Public Water System (PWS) Information

PWS Permit Owner/Holder (PO) Information

PWS Permit Billing (PB) Information

PWS Primary Certified Operator (CO) Information

Professional Engineer (PE) Information

Approval

Letter of Authorization

Permit Information

Permit Owner/Holder (PO) Information

Authorized Agent (AA) Information