Você está na página 1de 1

Department of Environment and Natural Resources

New Water System Application


This form is provided by the secretary of the South Dakota Department of Environment and Natural Resources in
accordance with 74:04:09:06 of the Administrative Rules of South Dakota. All new community and nontransient
noncommunity water systems must submit this form in order to be considered for a Certificate of Approval. Complete
this form and send to:
Drinking Water Program
523 E. Capitol Joe Foss Building
Pierre, SD 57501-3181

Applicant

Engineer

Owner/Developer:

Name/Firm:

Address:

Address:

City:

State:

Zip:

City:

State:

Zip:

Contact Person
Name:
Address:
City:

State:

Zip:

General Information:
County:
Legal Description (quarter, section,
township, range):

Project Name:
Water Source:
Service Population:
Yes o
Yes o
Yes o
Yes o

Has a layout map showing the location of the new water system been attached to this form?
Have drinking water sample results from the water source been attached to this form?
Has documentation of a valid water right permit been attached?
Has the business plan been submitted?

No o
No o
No o
No o

Certification
Applicant

Notary Public

I certify that I have read this application and that the matters
stated are true.

Subscribed and sworn to before me this ______ day of


___________________, _______.

Signature:

Date:

Notary Public Signature


(Stamp)

Você também pode gostar