Date: Site Fenced? Yes No General Scope of Project: Site Location: (also complete the last section of this table) 50’ Radius of Ownership? Yes No Maximum # of Lots (or population): INTERNAL STRUCTURE (sketch on separate sheet) Outer Casing Linear Feet: Thickness: Pounds/Foot: Joint: Type of Seal to Outer Casing: Inner Casing Linear Feet: Thickness: Pounds/Foot: Joint: Grouting Depth of grout: Thickness: Method With a Setting Time of? Screen Linear Feet: Type: EXTERNAL STRUCTURE (sketch on separate sheet) Casing Head Seal? Yes No Slab & Motor Foundation? Yes No Well Vent Diameter: (½”inch minimum) inches Down-Turned? Terminates 24” above 100-year Flood Level or floor whichever is greater? Twenty Four Mesh Screen? Watertight Seal at Casing? Yes No Yes No Yes No Yes No Drawdown Gauge: Type (seal): Pump Type: Power: Capacity (GPM): @ TDH (FT) Prime Mover: WATER WELL 2 of 2 DISCHARGE Discharge Piping Material:
PIPING Down-Turned Smooth-Nozzle Sample Tap? Check Valve? Shutoff Discharge Bypass? Pressure Gauge? Means of Measuring Flow? Yes No Yes No Yes No Yes No Yes No Yes No COMPLETION SPECIFICATIONS Disinfection Method: (include chlorine dosage and retention time) Drinking Water Analysis for New Water Sources Chemical testing to be performed to being placed into service? Yes No Bacteriological testing to be performed prior to being placed into service? Yes No Abandoned Holes? Yes No NAME OF CERTIFIED OPERATOR: LOCATIONAL INFORMATION Coordinates: Latitude ’ . Longitude ’ . OR Latitude . °N Longitude . °W Geographic Datum: WGS84 NAD27 Collection Method: GPS — DGPS/WAAS enabled? Yes No — Horizontal Accuracy? meters Map Specify: Scale: WATER SUPPLY BOOSTER STATION Project:
Engineer: Site Location: Water is Transmitted From: To: CONSTRUCTION Exterior Structure Length: Width: Height: Floor Material: Material: Ventilation? Yes No Floor Elevation (6” Above Finished Grade?) Yes No Interior Structure Lighting: Heating: Chlorination? Yes No Type: Floor Slope (3”/10’): Pumping Number: Type: Power: Capacity (GPM): @ TDH (FT) Piping Pipes to Pumps Size: Type: Pump Discharge Pipe Size: Type: Common Discharge Pipe Size: Type: Backflow Prevention? Yes No Type: GENERAL COMMENTS: WATER SUPPLY FINISHED WATER STORAGE 1 of 2 Project: Engineer:
PRESSURE TANKS Water Sight Glass? Automatic or Manual Air Blow Off? Pressure Switch For Pumps? Means for Adding Air? If Air Compressor, Give Capacity: CFM PSI Yes No Yes No Yes No Yes No TREATMENT PLANT STORAGE (clearwells only) Minimum Two Clearwell Compartments Provided? Yes No Disinfection Method: (include chlorine dosage and retention time, including calculations) Testing Yes No PIPING Influent: ( diameter-inches) (type of pipe) Effluent: (diameter-inches) (type of pipe) LOCATIONAL INFORMATION Coordinates: Latitude ’ . Longitude ’ . OR Latitude . °N Longitude . °W Geographic Datum: WGS84 NAD27 Collection Method: GPS — DGPS/WAAS enabled? Yes No — Horizontal Accuracy? meters Map Specify: WATER DISTRIBUTION SYSTEM Project: Engineer: Date: General Scope of Project:
PIPES Material: (specify ASTM standard, dimension ratio-DR, AWWA Standard, and pressure class) NSF 61 & NSF 372 Listed? Yes No Size: (Min 3” water main. Min 6” water main for fire protection. Water mains proposed with less than 3” diameter require justification with hydraulic analysis and future water use considerations provided and will only be allowed in special circumstances) JOINTS & MATERIALS: LAYOUT Valve Spacing: Means of Flushing Dead Ends? Yes No Number of Surface Water Crossings/Encounters? Location with Respect to Sewers: Maintain 18” Minimum Vertical Clearance @ Crossings? Yes No Maintain 6’ Minimum Horizontal Clearance? Yes No Normal Operating Pressure: Minimum System Pressure: DISINFECTION METHOD (include chlorine dosage and Retention time): and Operated By: (include name and address) NAME OF CERTIFIED OPERATOR: ADDITIONAL COMMENTS: DISINFECTION Project: Engineer: Date: General Scope of Project:
Site Location: TYPE OF DISINFECTION: Chlorine: Gas Solution Ammonia: Anhydrous (gas) Ammonium Sulfate (solution) Ammonium Hydroxide (Aqua Ammonia) (please explain): FEEDERS/PUMPS: # of Feeders/Pumps (2 minimum): Type: GENERAL: Standby Equipment? Stored in Areas Not in Direct Sunlight? Vented to Outside? Enough for 10 Days Storage? Yes No Yes No Yes No Yes No STORAGE OF CHLORINE GAS: Chlorine Storage & Feed System Building Separated? Doors Open Outward? Shatter-Resistant Inspection Windows? Fan/Light Switches Located Outside? Air Inlet Near Ceiling? Vent Fan Near Cylinders Restrained in Position? Weighing Scales? Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No STORAGE OF AMMONIA GAS or AQUA AMMONIA: Ammonia Storage & Feed System Building Separated? Fan/Light Switches Located Outside? Forced ventilation? Shatter-Resistant Inspection Windows? Leak Detection Systems in all Areas Through Which Ammonia is Piped? Yes No Yes No Yes No Yes No Yes No LIFT STATION (S) Project: Engineer: General Scope of Project: PUMPS # per Station:
SLUDGE DRYING BEDS Total Area: Area per Capita: Gravel Layer Depth: Sizes: Sand Depth: Under-drain Size: Freeboard Sand: Splash Plate? Yes No Effluent To: SLUDGE LAGOONS Number of Lagoons: Maximum Depth: Free Board: Volume of Each Lagoon: Volume of Each Lagoon per Capita: Pump: Piping Material: Size: Effluent To: OTHER SLUDGE DISPOSAL METHODS Explain: EXTENDED AERATION SEWAGE TREATMENT FACILITY 3 of 3 CHLORINATION Number: Gas or Hypo: Capacity (lb per 24 hrs): Test Kit: Location: Ventilation: CHLORINE CONTACT CHAMBER Inside Dimensions Length: Width: Operating Depth: Capacity (gal): Retention Time: (15 minute minimum @ peak hourly flow or maximum rate of pumping) Over-and-Under or End-Around Baffles? Yes No Scum Baffles? Yes No ADDITIONAL DETATILS Power Supply (Dual)? Yes No Washdown Facility? Yes No Backflow Prevention? Yes No Type:
Location: Levee Interior Slope: Exterior Freeboard: Crown Width: Surface Area Provided: Operating Depth: 2ND & 3RD CELLS Crossover Lines Material: Size: Depth Liquid Drawn From: Location: Water Surface Area Provided: Operating Effluent Line Material: Size: Liquid Drawn From: Variable Depth: OXIDATION POND 2 of 2 CHLORINE CONTACT CHAMBER Inside Dimensions Length: Operating Depth: Capacity (gal): Retention Time: (15 minute minimum @ peak hourly flow or maximum rate of pumping) Over-and-Under or End-Around Baffles? Yes No Scum Baffles? Yes No ADDITIONAL DETATILS Washdown Facility? Yes No Backflow Prevention? Yes No Type: Facility Fenced? Yes No Locked? Yes No Access Road? Yes No Copy of DEQ Administrative Completeness Determination Letter or Discharge Permit attached? Yes No
ADDITIONAL COMMENTS LOCATIONAL INFORMATION Coordinates: Latitude ’ . Longitude ’ . OR Latitude . °N Longitude . °W Geographic NAD83 WGS84 NAD27 Collection Method: GPS — DGPS/WAAS enabled? Yes No — Horizontal Accuracy? meters Map Specify: Scale: CERTIFICATION OF CONSTRUCTION Date: ___________________ Project Name: ______________________________________ ______________________________________ ______________________________________ ______________________________________