Form Bwa 001 B – Fill Out and Use This PDF

Report Form Recipient/Permit Contact (contact at the above address for permit information and monitoring reports):

4 . R E S P O N S I B L E E N T I T Y / O R G A N I Z A T I O N

If the responsible organization is the Applicant located in No. 3 above, check here: 

If the responsible organization is different from the Applicant in No. 3 above, complete the following:

Organization Name ________________________________________________ Telephone ( ) _________________

Mailing Address ____________________________________________________________________________________

City or Town_________________________________________ State ___________ Zip Code __________+_______

Fax ( ) _____________________________ E-Mail ____________________________________________________

6 . O T H E R P E R M I T S / A G E N C I E S

Provide the following for any other state, local or federal permit that has been applied for in relation to this project.

Water Quality Management Plan Amendment

Safe Drinking Water System/Potable Water Supply Well or Intake

Hazardous Waste Management Program

Land Use Permits (Freshwater Wetlands, etc.)

Relevant Environmental Permits – Including Federal, State, & Local Approvals – Specify:

Is the project located within the New Jersey Pinelands Area? ___ Yes ___No

If this application includes a new source of supply, which is located in the New Jersey Pinelands Area, or is for an increase in allocation, then a Certificate of Filing from the New Jersey Pinelands Commission must be submitted with the application. The Pinelands Commission can be contacted at (609) 894-7300.

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If Yes, has a docket been issued for this project by the Delaware River Basin Commission?

The Delaware River Basin Commission can be contacted at (609) 883-9500.

B . C E R T I F I C A T I O N S

In cases where the official required to sign Certification 1 below is the same person as the official required to sign the Certification 2 below, only Certification 1 need be signed. In all other cases, both certifications shall be completed.

1 . H I G H E S T R A N K I N G I N D I V I D U A L O F F A C I L I T Y

This certification is to be signed by the highest-ranking individual at the facility with overall responsibility for that facility.

I certify under penalty of law that the information provided in this document is true, accurate and complete. I am aware that there are significant civil and criminal penalties for submitting false, inaccurate or incomplete information, including fines and/or imprisonment.

(a)For a corporation, by a principal executive officer of at least the level of vice president; or

(b)For a partnership or sole proprietorship, by a general partner or the proprietor, respectively; or

(c)For a municipality, State, Federal or other public agency, by either the principal executive officer ranking elected official.

I certify under penalty of law that I have personally examined and am familiar with the information submitted in this application and all attached documents, and that based on my inquiry of those individuals immediately responsible for obtaining the information. I believe that the submitted information is true, accurate and complete. I am aware that there are significant civil and criminal penalties for submitting false, inaccurate or incomplete information, including the possibility of fines and/or imprisonment.

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3 . A P P L I C A N T ’ S A G E N T ( I F A P P L I C A B L E )

I, the Applicant/Owner __________________________________ or Applicant/Operator (when the owner of the

facility and the operator of the facility are distinct parties) __________________________________________

or Co-permittee (if applicable) ______________________________________________ authorize to act as my

agent/representative in all matters pertaining to my application the following person:

Name ________________________________________ Phone _____________________________________

Company/Employer ________________________________________________________________________

Occupation/Profession ______________________________________________________________________

4.STATEMENT OF PREPARER OF PLANS, SPECIFICATIONS, SURVEYORS OR TECHNICAL REPORT (IF APPLICABLE)

I hereby certify that the engineering plans, specifications and engineer's report applicable to this project comply with the current rules and regulations of the State Department of Environmental Protection with the exceptions as noted.

_____________________________________

(Signature of Engineer)

_____________________________________

Type: Name and Date

_____________________________________

Position, Name of Firm

PROFESSIONAL ENGINEER'S EMBOSSED SEAL

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2. Present annual average water use:

1Consumptive use is water withdrawn that is not returned to the surface or ground waters at or near the point from which it was taken without substantial dimunition in quantity or substantial impairment of quality.

3.The water, after use for above purposes stated in D.2., will discharge into ___________________________________

(Name of Stream, Sewage System, or Subsurface Disposal System). For wastewater discharged directly by the facility or via a sewerage system to treatment plant, provide the location of the plant and its NJPDES Permit Number. Location:_______________________________________________________________________________________

NJPDES Permit No. ________________________

4.For non-potable diversions, what is the source of water for sanitary use? ____________________________________

F . I R R I G A T I O N

Complete if water is to be used for irrigation purposes.

1. Check to ensure the following is included: Included

Attach a diagram of the irrigation system piping between the diversion sources, any storage ponds and wet wells, up to the irrigation system distribution piping. Include the position of all water meters.

2.Irrigation is to be used for (e.g. golf course, landscape, grounds maintenance)

______________________________________________________________________________________________

3.Describe the types of grasses, acreage and maximum need for each in extreme dry weather, in gallons per week.

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

4.Describe the irrigation system (type, capacity of nozzles in gpm, maximum number of nozzles operating at one time, average and maximum irrigation time in hours per day, how diversion is metered, how the ponds are fed.)

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

5. Is there any treated wastewater used for irrigation? ___Yes ___No

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I N S T R U C T I O N S F O R C O M P L E T I N G B W A - 0 0 1B

1 . G E N E R A L I N S T R U C T I O N S

This form includes eight sections, A through H, and Addenda A and B. Section F applies to irrigation water users (other than Agricultural/Horticultural water users certified by the County Agricultural Agent under N.J.A.C. 7:20A-1 et seq.). Section G applies to Public Water Suppliers. Addenda A and B apply to each individual diversion source for all applicants. All

applicable sections must be completed or the application will be returned.

Applications must reference valid State Well Permit Numbers and wells must be permitted for their intended use. A well search can be scheduled by the applicant or performed by the Department for a fee. Applications without valid State Well Permit

Numbers for existing wells will be returned.

All information required by the regulations under N.J.A.C. 7:19-2.2 must be addressed in this application.

A.Site Location Information

1.Actual Diversion Location - Provide the Name of the Facility of which the application is for, the physical street address or nearest cross streets of the diversion location. Attach additional sheets if more than one physical location applies.

2.Property/Land Owners – Provide the legal name for the owner of the property/land on which the diversion is located.

3.Applicant/Operating Entity(ies) – Provide the name, as it is legally referred to, of the operating entity of the subject facility. The operating entity is the firm, public agency, individual, or other entity which has the primary management and decision making authority over any part of the facility/site.

The Application Contact is the individual responsible for all aspects/inquiries regarding the application. Check the Agent box if an Agent has been designated in Section B3 of the Application. The Report Form Recipient/Permit Contact is the designated individual responsible for completing Quarterly Monitoring Report Forms. All Monitoring Report Forms will be mailed to the Report Form Recipient/Permit Contact designated at the Operating Entities address.

4.Responsible Entity/Organization – The person, company, or corporation financially responsible for the activity relating to the diversion and has overall legal responsibility of the activities occurring at the site. The organization liable or accountable for overall facility operations. The responsible entity may be the same as the Applicant/Operating Entity noted in Section A3. If so, check the appropriate box provided. If not, provide the requested information for the Responsible Entity

5.Billing Contact – Check the box of the appropriate address (either the Responsible Entity/Organization or the Applicant/Operating Entity) and indicate the individual contact for all billing inquiries.

6.Other Permits – Provide information for all other permits applied to in relation to the project and diversion activities, as indicated.

B.Certifications – Provide Certifications as indicated in Section B.

C.Required Submittals/Application Attachments

1.All diversion sources must be metered prior to treatment. Submit evidence to demonstrate that the flow meter for each source has been calibrated within the past five years. Also include the type of meter for each source. Evidence of meter calibration is not required for new sources (meters must be installed on all approved new sources, however). If the diversion is not metered at each source prior to treatment, please indicate why.

2.A completed Water Conservation and Drought Management Plan. Separate instructions and worksheets for completing the plan should be obtained by contacting the Bureau of Water Allocation & Well Permitting. A Conservation Plan is not required if the application is for ground water remediation, sand and gravel mining, or where diverted water is returned in undiminished quantity to its source.

3.Supporting information that shows how the future demands were determined in Section E.1. of the application.

For Sections D through G, please provide all information as requested in the section.

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