Iowa Admin. Code r. 567-40.3 - Forms

The following forms are used by the public to apply for department approvals and to report on activities related to the public water supply program of the department. All forms may be obtained from the department's website atwww.iowadnr.gov (water supply pages) or from the Environmental Services Division, Administrative Support Station, Department of Natural Resources, Henry A. Wallace Building, 502 East Ninth Street, Des Moines, Iowa 50319-0034. Properly completed application forms shall be submitted to the Water Supply Section, Environmental Services Division. Water supply system monthly and other operation reporting forms shall be submitted to the appropriate field office (see 567-subrule 42.4(3)). Properly completed laboratory forms (reference 567-Chapter 83) shall be submitted to the State Hygienic Laboratory or as otherwise designated by the department.

(1) Construction permit application forms. Schedules "la" through "16d" are required.

Schedule No.	Name of Form	Form Number
"1a"	General Information	542-3178
"1b"	Minor Water Main Construction Permit	542-3151
"1c"	Fee Schedule	542-3179
"2a"	Water Mains, General	542-3030
"2b"	Water Mains, Specifications	542-3031
"2c"	Notification of Minor Water Main Construction	542-3152
"3a"	Water System, Preliminary Data	542-3032
"3b"	Water Quality Data	542-3029
"3c"	Surface Water Quality Data	542-3028
"4"	Site Selection	542-3078
"5a"	Well Construction	542-1005
"5b"	Well Appurtenances	542-3026
"5c"	Well Profile	542-1006
"5d"	Surface Water Supply	542-3139
"6a"	Distribution Water Storage Facilities	542-3140
"7"	Schematic Flow Diagram	542-3142
"8"	Aeration	542-3143
"9"	Clarification/Sedimentation	542-3144
"10"	Suspended Solids Contact	542-3145
"11"	Cation Exchange Softening	542-3146
"12"	Filters	542-3147
"13a"	Chemical Addition	542-3241
"13b"	Dry Chemical Addition	542-3130
"13c"	Gas Chlorination	542-3131
"13d"	Fluoridation	542-3132
"13e"	Sampling and Tests	542-3133
"14"	Pumping Station	542-3134
"15"	Process Water Storage Facilities	542-3135
"16a"	Wastewater, General	542-3136
"16b"	Waste Treatment Ponds	542-3137
"16c"	Filtration and Mechanical	542-3138
"16d"	Discharge to Sewer	542-3103

(2) Operation permit application forms.

a. Form 13-2 - application for a new water supply 542-1300

b. Form 13-3 - renewal application for an existing water supply 542-1301

(3) Water supply reporting forms. The monthly water supply operation report forms are available from the department's water supply operations section website. The laboratory analyses for compliance samples are reported via electronic means directly to the department by each certified laboratory.

(4) Laboratory certification application forms. Reserved.

Notes

Iowa Admin. Code r. 567-40.3

ARC 9915B, IAB 12/14/11, effective 1/18/12 Amended by IAB April 11, 2018/Volume XL, Number 21, effective 5/16/2018