00-0115-002 : .: 12509-90.1 DSdP
Deoai=tiiient of
Environmental Protection
FtoRtda
Notification for Use of the Ccneral F'ermit-for-Construction of an Extension to a
Public Drinking Water Distribution System
VSTRUCTIONS: This form shall be completed and submired by persons;proposing to construct projects permitted under the
General Permit for Construction of an E:aa�nsic,n �c, a Public Giinkirlg-Water Distribution System" pursuant to Rule 62-555.540,
lorida Administrative Code (F.A.C.). AT LEAST 30 DAYS BEFORE BEGINNING THE PROPOSED CONSTRUCTION,
omplete this form and submit it in quadruplicate to the appropriate district office of the Department or the appropriate Approved
;ounty Public Health Unit(ACPHU) along with a check for the proper permit processing fee and the following supporting
!ocuments: signed and sealed engineering design data, plans, and specifications and a certificate that the project has been
approved by the governing body of the permittee (city commissioners, corporation, board, etc.). All supporting documents, as
vell as this form, shall be submitted in quadruplicate. All information provided on this form shall be typed or printed in ink. A
ignature page or cover letter for engineering design data, each sheet of engineering plans, and a cover or index sheet for
-type metal seal
!ngineering specifications shall be signed, dated, and sealed with an impression e i ntended for construction and
the professional engineers)
n responsible charge of the documents. Also, engineering,plans and specifications shall be those
;hall nQ2 be stamped otherwise (e.g., "For Permitting Only, For Review Only," etc.). Permit processing fees are listed in Rule
32-4.050, F.A.C. Checks for permit processing fees shall be made payable to the Department of Environmental Protection or the
appropriate ACPHU. NOTE THAT A SEPARATE NOTIFICATION AND A SEPARATE PERMIT PROCESSING FEE ARE
REQUIRED FOR EACH NON-CONTIGUOUS PROJECT. Jig
Project Name: s
Project Description:
1 fl AI Il � �Ofi
17aa� �nunty Department
of Public hCiiu
,n
!Project Location Ran e:
County: ��1��%• 1'2 Section: 2b Township: g
!Permittee
Utility/Company Name: — Telephone No.: �05�
Address: -�O
City: 1--�1�� .-�
• � State: �-� Zip Code:
iPublic ^later$yt�m $�pglyinq Water for Project
System Name: t✓�� - cam- PWS Identification No.:
System Owner: � Telephone No.:
Address: 3
City: i--1�ra-�-�1 State: �y_ Zip Code: 3
!Owner/O r for of Project After It Is Pla sed into SerYice Telephone No.:
Utility/Company Name:
Address:
City: State: Zip Code:
!Prof( c
Name of Engineer:
Telephone No.:
Firm Name:
Address: ��` 331-J(o
City; r-A, State: yL Zip Code:
DEP Form 62.555.900(7) Page 1 of 5
Enecrvg_Dec=th-_ 1o,1996