APPENDIX_D_-_DRINKING_WATER_CONSTRUCTION_PERMIT.pdf

Project Request No. 2017-3523 Date: 5/21/2018

Appendix D

Drinking Water

Construction Permit

FOR

REPAIR WATER LINES

IN PARKING LOT 3H

ROCK ISLAND ARSENAL

ROCK ISLAND, ILLINOIS

ENGINEERING AND SERVICES DIVISION

DIRECTORATE OF PUBLIC WORKS

FY2018

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Rev. 5/2017

Application for Construction Permit

Page of

Illinois Environmental Protection Agency

1021 North Grand Avenue East

P.O. Box 19276

Springfield

Illinois

62794-9276

(217) 782-3397

Division of Public Water Supplies Application for Construction Permit

The regulations referenced in this application are taken from the Illinois Environmental Protection Act, 2007. All subsequent rules, regulations, and violations listed in this document can be found within the Act. This application may be completed online, a copy saved locally, and printed before it is signed and mailed to the Illinois EPA.

5. Documents being Submitted:

6. Scope of Project:

7. Illinois Commerce Commission: Are you a privately owned water company subject to Illinois Commerce Commission rules?

8. Infringement on Other Public Water Supplies: Will any part of this project be located within the boundaries of an area served by another PWS?

9. Certifications

NOTE: Each person signing this application certifies that the information in the application is complete and accurate, and that the text of the application has not been changed from the Agency's official construction permit application form.

9.1) Certificate by Design Engineer

I hereby certify that I am familiar with the information contained in this application, and that to the best of my knowledge and belief such information is true, complete and accurate.

9.2) Certificate by Applicant(s) to Construct

I hereby certify that I have read and thoroughly understand the conditions and requirements of this submittal. I/the representative company hereby agree to conform with the Standard Conditions and any Special Conditions made part of this Construction Permit.

9.3) Water Main Fees

Section 16.1 of the Illinois Environmental Protection Act (Act) requires the Agency to collect a fee for certain applications for the installation or extension of water mains. There are no permit fees for other improvements (for example, treatment facilities) to public water supply systems and only certain water main projects are affected. The Agency will not approve any construction application without the required fee. Except for the conditions listed in Section 9.4, the following fee schedule applies per Section 16.1(d) of the Act:

Fee : Total Length of Water Main

Please check the appropriate fee; make check or money order payable to: Treasurer, State of Illinois and submit along with this application. Any fee remitted to the Agency shall not be refunded at any time or for any reason, either in whole or in part.

9.4) Water Main Fee Exceptions - READ CAREFULLY BEFORE SIGNING THE FOLLOWING

The Water Main Permit fee does not apply to:

Any Department, Agency or Unit of State Government.Any unit of local government where all of the following conditions are met:The cost of the installation or extension is paid wholly from monies of the unit of local government, state grants or loans, federal grants or loans, or any combination thereof.The unit of local government is not given monies, reimbursed or paid, either in whole or in part, by another person (except for State grants or loans or federal grants or loans.

I, hereby certify that this project meets the above criteria.

DO NOT SIGN HERE UNLESS PROJECT MEETS FEE EXCEPTION CRITERIA.

9.5) Agreement to Furnish Water (this section must be completed if applicable)

The has agreed to furnish water to the area in which water main extensions are proposed by according to plans titled prepared by

The undersigned acknowledges the public water supply's responsibility for examining the plans and specifications to determine the proposed extensions meet local laws, regulations, and ordinances.

9.6) Certification by Owner(s) of Completed Public Water Supply Improvement(s)

I hereby certify that I have read and thoroughly understand the conditions and requirements of this submittal. I hereby agree to accept ownership of the project upon satisfactory completion.

NOTE: Applications signed by a person other than a responsible municipal official, corporation officer, or owner, must be accompanied by evidence of authority to sign the applications, unless documentation of such authority is on file with the Division of Public Water Supplies.

Felony Warning: Any person who knowingly makes a false, fictitious, or fraudulent material statement, orally or in writing, to the Illinois EPA commits a Class 4 felony. A second or subsequent offense after conviction is a Class 3 felony (415 ILCS 5/44(h)).

This Agency is authorized to require this information under Illinois Compiled Statutes, 415 ILCS 5/39 (2000). Disclosure of this information is required under that Section. Failure to do so may prevent this form from being processed and could result in your application being denied.

Illinois EPA Bureau of Water

David Cook

5/11/2017

Drinking Water

Wally Hartshorn

Application for Construction Permit

5/26/2017

CurrentPage:

PageCount:

Please enter name of owner of completed project:

FacilityID: IL

Please select a county from the drop-down list:

Provide a specific address or other general description of the location here:

Enter name of plans here:

Provide the number of pages included in the plan here:

AppforPermit: 0

ScheduleA: 0

ScheduleB: 0

Specs: 0

ConstDrawings: 0

EngDesign: 0

ScheduleC1: 0

ScheduleC2: 0

PermitFee: 0

Scope:

If you selected Yes, please explain how this applies to your project:

No:

Infringement:

Name:

Registration:

Enter engineering firm name here:

Please enter address of owner here:

Please enter owner's city here:

Enter the 2-letter state abbreviation.:

Please enter owner's zip here:

Phone:

Email:

Signature:

Please enter owner's zip here:

Enter applicant to construct info here:

Check the amount that corresponds to the total length of the new water main. Even if the project will contain partial permits, only one fee will apply. Add the length of all partials; that will give you the total length of water main. This is what your water main fee is based on. Emergency construction permits: The appropriate fee shall be submitted to the Agency within 10 calendar days from the date of issuance of the emergency construction permit. See Sec. 16.1 (c) and (d) of the Act for detailed explanation of fees.:

Fee2:

Fee3:

Fee4:

Enter city, town, village, water company or water authority here:

Enter city, town, village, water company or water authority here:

Title:

PrintedName: To be Provided by the Government

PrintedTitle: To be Provided by the Government

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Page of

Illinois Environmental Protection Agency

1021 North Grand Avenue East

Springfield

Illinois

62794-9276

Bureau of Water

P.O. Box 19276

Division of Public Water Supplies, Permit Section Schedule B - Water Main Construction

This form may be completed online, a copy saved locally and printed before it is signed. You may also complete a printed copy manually. Submit the completed and signed form to the Illinois EPA, Division of Public Water Supplies, Permit Section at the address listed above.

Name of Public Water Supply:

Enter name of community water supply here

ID# IL:

Project Title:

Enter the name of the project here

1. Check the appropriate boxes to indicate the specifications to be used for the water main:

(MGD)

(MGD)

(MGD)

(MGD)

(MGD)

(MGD)

(PSI)

(PSI)

(PSI)

(PSI)

IL 532-0159

PWS 56 4/2015

This Agency is authorized to request this information under 415 ILCS 5/4(b)(2012). Disclosure of this information is voluntary and no penalties will result from the failure to provide the information. However, the absence of the information could prevent your application from being processed or could result in denial of your application from being or could result in denial of your application for certification. This form has been approved by the Forms Management Center.

14. Water mains to be installed must be listed below:

Pipe size (inches)

Total Length (feet)

15. Provide the general material specifications and type of joints:

17. Disinfection:

E. Provisions must be made for collection of water samples to be collected for bacteriological analysis on two consecutive days taken at 24-hour intervals.

18. Sewer and Water Separation:

Minimum horizontal and vertical separation requirements of this Agency to be followed:

If "No", explain provisions for protection of water main:

19. List all deviations from this Agency's design criteria and state justifications for deviations.

Schedule B (cont'd)

(mg/L)

(mg/L)

(hrs)

9.0.0.2.20120627.2.874785

CurrentPage:

PageCount:

Adobe Reader 8 upgrade:

Enter name of community water supply here:

Enter 7-digit ID number here:

Enter the project title here:

StdSpecs: 0

Engineer: 0

PWS: 0

Specs: 0

ExisitingPop: To be Provided by the Government

WaterMainExt: To be Provided by the Government

AvgDailyPump: To be Provided by the Government

MaxDailyPump: To be Provided by the Government

CapacityWaterWorks: To be Provided by the Government

CapacityRaw: To be Provided by the Government

CapacityExistingLines:

CapProposed:

NormalPressure:

Minimum:

Pressure:

Calculated:

Cell1:

Cell2:

Cell3:

Cell4:

Cell5:

Cell6:

TextField1:

Cover:

Chem: To be Provided by the Government

Initial: To be Provided by the Government

Final: To be Provided by the Government

Retention: To be Provided by the Government

Yes:

No: