Application for Operating Permit

IL 532-0140

PWS 037 Rev. 3/2022

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, Permit Section

Application for Operating Permit

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.

Facility Name:

Address 1:

Address 2:

City: State: Zip Code:

County:

Facility ID:

Construction Permit No.:

Permit Type:

Date Permit Issued:

Project Title:

Firm Name:

Project Status:

Final

Partial

Partial A, B, C, etc.

Application Requirements (check when complete):

Permit Number, Facility Number, and Facility Name identified on the Lab Report(s).

Sample results attached to the Application.

(If a new well was constructed, provide a copy of the sample results

as required by Section II, Part g of the C-I application).

For water main projects subject to Section 17.12 of the Act (415 ILCS 5/17.12),

attach a statement on lead service lines and a copy of the lead informational notice

(if one was distributed). See the instructions page for additional information.

If you select Partial, you must also submit the following items:

Cover letter describing which sections were completed.

General project layout plans.

For water main projects, identify the length the Partial:

Date of Project Completion:

(Provide the date construction was completed on the project or partial)

Certified Operator in Responsible Charge:

Name:

Classification:

Number:

Telephone: Email (optional):

Owner of the Completed Project:

Name: Title: Telephone:

Address:

City: State: Zip Code:

The Owner hereby certifies that the project named and described has been constructed in accordance with plans and specifications

approved by the Illinois EPA. See instructions for further information. For Verbal Approvals, please call 217-782-1724.

Owner/Authorized Personnel Signature Date

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))

FOR IEPA USE ONLY

This operating permit issued on

is valid until revoked.

This permit is valid only for the work completed under the Construction Permit of the same number.

David C. Cook, P.E.

Manager, Permit Section

Division of Public Water Supplies

-FY

IL 532-0140

PWS 037 Rev. 3/2022

Application for Operating Permit

Instructions for Operating Permit Application

The Operating Permit Application must be submitted for all Public Water Supply projects that required a construction permit.

The Operating Permit must be obtained before the project is placed in service.

Fill out the top section using the corresponding Construction Permit for reference.

• Facility Name is the name of the village, city or entity distributing community water supplies.

• Facility ID Number can be found on the Construction Permit. This number is specific to your facility.

• Address is the same as the address on the Construction Permit.

• Construction Permit Number is the assigned permit number of the corresponding Construction Permit. The Operating Permit

and the corresponding Construction Permit will have the same permit number.

• Permit Type identifies whether the project involved is a Water Main, a Plant Improvement or Both.

• Date Permit Issued is the date the Construction Permit was granted.

• Date of Project Completion is the date construction was completed for the section of project you are requesting the Operating

Permit for. If you are requesting an Operating Permit for a Partial project, the Date of Project Completion is the date

construction was completed on that partial section. The Date of Project Completion will never be a date in the future, and must

be a date after the issue date of the Construction Permit.

• Title of Project is the same title of project listed on the corresponding Construction Permit. The Operating Permit and the

Construction Permit will have the same Title of Project.

• Firm Name is the engineering entity that designed the project.

Project Status will either be Final or Partial.

• Final: If construction on the project is complete, you will select Final.

• Partial: If construction on the total project is only partially complete, but you want to operate the completed section, you will

select Partial. If this is the first partial, you will identify it as “Partial A”, if this is the second partial, you will identify it as “Partial

B” and so forth. Once the last partial section has been completed, identify it as such and also select Final in the Project Status.

The Certified Operator in Responsible Charge and Owner of the Completed Project should fill out his/her respective section.

Please print your name legibly and sign where appropriate. By signing the application, the owner hereby certifies that the project named

and described has been constructed in accordance with plans and specifications approved by the Illinois EPA, including specifications

for bacteriological samples, and that bacteriological samples (if required) were taken under the supervision of a representative from the

Public Water Supply. The owner also certifies that the project will be operated in accordance with the provisions of the Illinois

Environmental Protection Act and the Rules and Regulations adopted by the Illinois Pollution Control Board pursuant to provisions of the

Act.

Requests for Verbal Approval and questions can be addressed at (217) 782-1724.

Disinfection and bacteriological analysis must be performed for the completed project in accordance with the requirements of AWWA

C651, C652, C653 or C654. For projects requiring these procedures, the sample results must be attached to the application. The

construction permit number should be clearly visible on the sample results. Two consecutive sets of samples collected at least 24 hours

apart must show the absence of coliform bacteria and the presence of a 0.5 mg/L minimum free chlorine residual or a 1.0 mg/L minimum

combined chlorine residual. Samples must be collected every 1,200 feet of new water main along each branch and from the end of the

line unless otherwise approved by the Illinois EPA.

All operating permit applications for water main construction permits that have additional conditions for lead service line inventory,

replacement, and notification must include a statement indicating either that no full or partial lead service lines were identified or that

they were replaced in accordance with Section 17.12 of the Act, 415 ILCS 5/17.12. A copy of the Lead Informational Notice satisfying

the requirements of Section 17.12(jj) of the Act, 415 ILCS 5/17.12(jj) must also be attached. The notice must contain the following

statement translated in the Spanish, Polish, Chinese, Tagalog, Arabic, Korean, German, Urdu, and Gujarati languages: “This notice

contains important information about your water service and may affect your rights. We encourage you to have this notice translated in

full into a language you understand and before you make any decisions that may be required under this notice.”

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 form to the Illinois EPA, Bureau of Water, Permit Section at the following address:

Illinois Environmental Protection Agency

Division of Public Water Supplies, Permit Section #13

1021 North Grand Avenue East, PO Box 19276

Springfield, IL 62794-9276