Forms: Division of Drinking Water

Electronic Forms

• Seasonal Start-Up
• Level 1 Assessment Form
• Distribution System Chlorine Residual Online Form

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Capacity Assessment

Capacity Assessment Worksheets for Public Water Systems

Can be submitted online. Print out your form for your records before submitting online. Alternatively, this form can be mailed to our office or faxed to (801) 536-4211, Attn: Nagendra Dev

Financial Information

Contact Nagendra Dev ([email protected]) if you have questions.

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Construction of Public Water Systems and Drinking Water Facilities – Plan Review

Application for a New Public Water System

• New Public Water System Information Form

Capacity Evaluation – Source and Storage

• PWS Capacity Calculations Spreadsheet (protected)
• PWS Capacity Calculations Spreadsheet (unprotected)

Hydraulic Modeling

• Hydraulic Analysis Certification Form
• Hydraulic Model Design Elements & System Capacity Expansion Report Form
• Hydraulic Model Design Elements Report Form
• Hydraulic Modeling Rule Summary

Operating Permit

• Operating Permit Checklist

Plan Review Checklists

• Alternative Surface Water Treatment
• Conventional Surface Water Treatment
• Disinfection – Chlorine
• Disinfection – Chlorine Dioxide
• Disinfection – Ozone
• Disinfection – UV
• Distribution Systems
• Fluoridation
• Membrane for Surface Water Treatment
• Miscellaneous Treatment Methods
• Pump Stations
• Spring Sources
• Surface Water Sources
• Water Storage Tanks
• Well Sources

Plan Review – Other Documents

• Chlorine Dose Calculator (Protected)
• Chlorine Dose Calculator (Unprotected)
• Disinfection CT Calculator
• Inorganics and Organics Treatment – Internal Review Checklist
• Policy for Dichlor and Trichlor Disinfection
• Project Notification Form
• Public Drinking Water Project Definition
• Surface Water Treatment – Internal Review Checklist
• Water/Sewer Separation – Plan Review & Exceptions

Seasonal Start-up

• Seasonal Start-up Procedure Checklist

Source Development

• Aquifer Storage and Recovery Requirements
• Spring Development Checklist
• Well Development Checklist

Water Line Installation Standards

• Application for Approved Water Line Standards
• Approved Water Line Standards Fact Sheet

Water Hauling

• Water Hauling Proposal – Approval Form (PWS Receiving Hauled Water to submit to DDW)
• Guidance For Hauling Drinking Water
• Water Hauling Report (PWS Receiving Hauled Water to submit to DDW)
• Printable Water Hauler Checklist (Water Hauler to submit to PWS Receiving Hauled Water)

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Data Locations Submittal

Location Data for Public Water Systems

Can be submitted online by clicking the Submit Form button in Adobe Acrobat (Reader or Pro versions). Note: open the PDF in Adobe Acrobat directly.  Alternatively, this form can be mailed to our office or faxed to (801) 536-4200.

Contact Deidre Beck ([email protected] ([email protected])) with questions.

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Deficiency Reporting (Sanitary Survey)

IPS Deficiency Correction Notice

Email, mail, or fax to us:  [email protected] or fax to (801) 536-4211, Attn: Jennifer Yee ([email protected]).

Adobe Reader Users Fill out the form, select the “Submit by Email” button, and Email the xml file to [email protected] using the Wizard to create the xml file. Note: If you are using the Chrome browser, the Adobe Reader plug-in won’t work. Use Internet Explorer or open the PDF in Adobe Reader directly.

Adobe Pro Users Fill out the form, save the PDF, then Email the PDF file to [email protected] (using the Wizard to create the xml file). Note: If you are using the Chrome browser, the Adobe Reader plug-in won’t work. Use Internet Explorer or open the PDF in Adobe Reader directly.

Adobe Pro Users Fill out the form, save the PDF, then Email the PDF file to [email protected].
See also Sanitary Survey.

Contact us at [email protected] ([email protected]) with questions.

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Disinfection By-Products (DBP) Rule

The EPA has a Quick Reference Guide available for Stage 2.

• DBP Sampling Plan 
• DBP Fact Sheet 
• Quarterly Chlorination Report (42.36 KB)

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Operator Certification

• To Update Contact Info: For operators and water systems. If you have a new phone number, email address, or have recently moved, use this form to let us know how best to reach you. We require written notification of contact info changes. Reach us at (801) 536-4200 to get started.
• Individual CEU Application
• Course CEU Application: XLSX
• Exam Application
• Reinstatement Application
• Renewal Application
• Unrestricted Certificate Application
• Citizenship Certification Form

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Financial Assistance

SRF Application

A combined form in MS Excel for both State and federal SRF; Email to DDW ([email protected]) once complete.

Division of Water Resources Conservation Program

To receive funding, a water management and conservation plan must be submitted.

EPA/WBE Utilization Under Federal Grants and Cooperative Agreements

Utilization under federal grants, cooperative agreements, and interagency agreements form.

Pre-Award Compliance Review Report

For all applicants requesting federal financial assistance.

State Revolving Fund | Drinking Water Board Schedule

To present a project to the Utah Drinking Water Board in a particular month, certain deadlines apply.

See also Construction Assistance.

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GRAMA Information Requests

See Records Request.

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Groundwater (GW) Rule

• 4-log Chlorine Contact Report Form

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Lead and Copper Sampling

• Consumer Notice Lead and Copper Water Sample Results:

• Creating a Lead and Copper Sample Site Plan 
• Lead and Copper Certification: Online Form
• Lead and Copper Consumer Notice Certification Form:

• Lead in Schools Checklist 
• Public Education Requirements for AL Exceedance 
• Sampling Procedure Guidance for Homeowners 
• Sampling Procedure Guidance for Homeowners (Spanish) 
• Summary Sheet & 90th Percentile Calculator 

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Public Notification

See Public Notification Templates.

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Source Protection

If you have an updated source protection plan to prepare, the following links for a template and for waiver forms to use to reapply for Use and Susceptibility Waivers are available:

• Groundwater Plan Checklist
• Surface Water Update Template
• Surface Water PER Checklist
• Surface Water Plan Checklist
• Ground Water Update Template
• Susceptibility Waiver Statement
• Use Waiver Statement
• Waiver Checklist

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Water Treatment Facilities (Operational Reports)

For complete treatment plants:

• Disinfection Profiler Spreadsheet
  This spreadsheet calculates a disinfection profile for one month. Allows for up to 20 disinfection sequences. It can be used for the following disinfectants: chlorine; chloramines; chlorine dioxide; and ozone.
• Interim Enhanced Surface Water Treatment Rule (IESWTR)
  For plants on systems serving 10,000 or more.
• Monthly Electronic Report (03/14/2016)
  This is an electronic form for operators of complete treatment plants. It can be completed and Emailed back to the Division