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HomeMy WebLinkAboutApplication for Drinking Water System PermitV2V 7,0 STATE OF FLORIDA MDEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES APPLICATION FOR DRINKING WATER SYSTEM PERMIT AUTHORITY; Chapters 381.0062 & 403.862, Florida Statutes, and 1OD-4, F.A.C. 77 GENERAL INFORMATION4EE INSTRUCTIONS ON'aACK Application, Type Water System Type Please mark one box from Q Construction 0 Limited Use (L.U.) Community each column to indicate the Q Alteration 0 L.U. Commercial type of application and system: Q Operation 0 Private system for 3-4 residences BUSINESS NAME C• >• 2EL yLL //✓G -2;" , DESCRIBE TYPE OF BUSINESS SQUARE FEET ADDRESS CITY STATE ZIP OWNER/APPLICANT NAME (circle one) ADDRESS CITY STATE ZIP BUSINESS PHONE ( 1 HOME PHONE ( 1 PERMITTING AGENCY PERMIT NUMBER WELL CAPACITY (GPM) CONTRACTOR LICENSE NUMBER DATE COMPLETED COMPLETION REPORT ATTACHED (Y/N) _ GROUT FROM WELL BOTTOM (FT) GROUT FROM WELL TOP (FT) WATER SYSTEM INFORMATION. DAILY FLOWa(GPD) PEAK DEMANDaa(GPM) IRRIGATION/OTHER USE WELL AND/OR HIGH SERVICE PUMP CAPACITY (GPM) / GROSS PRESSURE TANK VOLUME (GAL) BLADDER TANK CAPACITY (GAL) _ STORAGE TANK(S) BRAND & MODEL TOTAL LENGTH OF DISTRIBUTION PIPE (FT) MATERIAL COMPLETE THE FOLLOWING TABLE WITH INFORMATION ABOUT PROPOSED OR EXISTING TREATMENT: TREATMENT BRAND MODEL CAPACITY from table II in 1OD-6, F.A.C. - from PD calculations in 1OD-4.025(7), F.A.C. COMPLETE THE FOLLOWING ONLY WHEN DISINFECTION'IS USED, CONTACT TANK VOLUME (in addition to tanks listed above), BRAND M1.ODEL OXIDANTDEMANDOF WATER (MGIL) TTHMFP IMG/U ,tAB ID A m voarnp,w enr,anappncant nsreay spray to operne me onn im warm system in accommos anm me reauremama of Sacaon 361.00u2, Florida Statutes, and chapter 1 ODA, Florida Admirsstratiw Code. Thu Information comaind in this application, which sannis w tln basis for parmittirp, is tn.o arW eerram. I tndentand that any miamprwontation of facts in this application, or fslva to comply with sw%AW standards, Is ar.0 . for dorsal, admirsstrstn, fins, or w0c4tion of the warm Mom permit. HRS-H Form 4092, Jul 93 (Stock Number: 5744-000-4092-1) INSTRUCTIONS FOR COMPLETING HRS-H FORM 4092 ✓'` �' The applicant shell provide all information requested on this application. It will be used`by the department to determine if a proposed or an existing water system meets the standards specified in Chapter 1OD-4, Florida Administrative Code, Drinking Water Systems. The applicant must attach: two copies of a site plan drawn to scale depicting the water system, including the well and any contaminant sources within setbacks specified by rule, two copies of a construction plan specifying the components of the water system, the appropriate fee, all water quality analyses conducted, and well construction information (the permit or well completion report). Upon completion of new system construction or alteration, the applicant shall notify the department for final inspection and receive approval of the system prior to using the water system. For existing water systems, if information is unavailable or unknown, write "unk" in space provided. GENERAL INFORMATION Application Type: Mark the appropriate box with an X if the permit application is for initial construction, existing system alteration, or for an annual operation permit. Water System Type: Mark the box for a Limited Use Community Public Water System if your water system serves five (5) or more nonrental residences, or two (2) or more rental residences. Mark the box for L.U. Commercial if the system serves a non-residential establishment (a business), and a bottled water use exemption has not been filed with the department. Mark the box for Private system for 3-4 residences if the system serves three (3) or four (4) nonrental residences. Private water systems serving one (1) rental residence and/or a single owner -occupied residence are not regulated by this rule, and therefore do not need to apply for a permit. Where tap water is not available for consumption (via water fountains or food preparation) or for bathing, and certain other conditions are met, the owner may choose to register for a bottled water use exemption on HRS-H Form 4095, Registration For Exemption From Drinking Water System Permit. Contact your county public health unit's environmental health or engineering section during normal business hours for a copy of this form. The remaining information requested in thissection is self-explanatory. WATER WELL INFORMATION If the water well was permitted by the Water Management District or another agency, write the name of that agency and the permit number in the spaces provided. The mandatory well completion log prepared by the water well contractor can provide the information on well capacity, contractor, date, and grout. Mark Yes or No if a well completion report is provided with the application. WATER SYSTEM INFORMATION Daily flow is based on table II in chapter 10D-6, F.A.C., and is recorded in gallons per day. Peak demand in gallons per minute is calculated using the formula from chapter 1OD-4, F.A.C.; the formula is: PD = [(GPD/T) x 4.51/6p + IF, where GPD is daily flow. T is daily time of operation in hours, and IF is an irrigation factor. Describe the type of use in the irrigation/other use space. Record the well pump capacity in gallons per minute, and the high service pump capacity, if one exists to pump from a non -pressurized storage tank. Grose pressure tank volume includes all pressurized storage volume and includes normal working water volume plus air volume in tank(s). A formula that compensates for air volume is included in section 1OD-4.025(7). For bladder tanks, state the drawdown (usable) volume and pressure range. Include name brand and model number from both tank types to verify that US FDA or ANSI/NSF standards are met. Distribution pipe length includes lengths of all pipe sizes from the system to building. connection. Pipe material is usually PVC, PB, galvanized steel, or iron. Treatment type, brand of device, model number, and capacity of equipment used to treat water must be provided for each type proposed or installed. Use additional paper if more space is needed. WHEN DISINFECTION IS USED Provide the contact tanklal volume in gallons when one is used in conjunction with a bladder pressure tank. Provide the chemical oxidant demand of the water prior to disinfection, and the total trihalomethene formation potential (TTHMFP). Include the lab ID number of the certified HRS laboratory that conducts the test. APPLICANT MUST COMPLETE, READ, AND SIGN THE APPLICATION. PLEASE DO NOT MARK IN THE SECTION FOR HRS USE ONLY.