Form Bwse Pci 145 PDF Details

Navigating the complexities of ensuring safe and compliant water connections can often be intricate for businesses and property owners. The State of New Jersey acknowledges this challenge and has established a structured process to streamline applications for physical water connections through the Bwse Pci 145 form. This document is a critical tool administered by the Department of Environmental Protection, specifically under the Division of Water Supply & Geoscience. It serves as an initial application for entities seeking to establish or modify a physical connection to public water systems. The comprehensive form not only gathers detailed applicant and facility information but also mandates the disclosure of backflow prevention plans, a critical component in safeguarding water quality. Applicants are required to specify whether existing permits are in place, the intent to incorporate listed backflow preventer(s) into the permit, and provide illustrations of facility layouts highlighting the proposed or existing water supply connections and backflow prevention mechanisms. Additionally, the form facilitates a collaborative review process, necessitating approvals from public water system representatives and local administrative authorities, ensuring that every connection adheres to stringent safety standards. With a clear set of instructions and a $150.00 processing fee, the form aims to simplify the application process while emphasizing the importance of protecting public health through meticulous water supply management and backflow prevention.

QuestionAnswer
Form NameForm Bwse Pci 145
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namespreventer, concurs, unapproved, BWSE-PCI-145

Form Preview Example

BWSE-PCI-145

 

 

 

Page 1 of 2 02/13

Physical Connection Permit Number

-WPC

 

State of New Jersey

 

 

 

DEPARTMENT OF ENVIRONMENTAL PROTECTION

Division of Water Supply & Geoscience - Bureau of Water System Engineering

Mail Code 401-03, 401 East State Street – P.O. Box 420, Trenton, New Jersey 08625-0420

Application Form for Initial Physical Connection Permit

1/ Applicant Details

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Applicant/Owner/Company Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Permanent Legal Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City/Town

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State

 

 

 

 

 

 

 

 

 

 

 

Zip Code

 

 

Telephone (

 

)

 

 

 

 

 

 

Fax Number (

)

 

 

 

 

 

 

 

e-mail

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Contact Person Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Title

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2/ Details of Facility

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Facility

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address of Facility (Street/Road)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Municipality

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

County

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Zip Code

 

 

 

 

 

 

 

 

 

 

 

Block

 

 

 

 

 

 

 

 

 

 

Lot

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Do you have an existing Physical Connection Permit?

 

 

 

 

 

 

 

Yes

 

No

If yes, enter Permit Number

 

 

 

 

-WPC

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Do you want to add the backflow

preventer(s) listed on Page 2 of this application to this permit?

 

 

 

 

Yes

 

No, I want a separate permit.

 

 

 

 

 

Are the backflow preventer(s) already installed?

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

Number of new backflow preventer(s) under this application:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3/ Details of unapproved supply

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Source of Unapproved Water:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Unapproved Water Used for:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cross Connection Exists or

 

 

Public Water & Unapproved Water Exist Within Same Building

If from Well(s): number of wells

 

 

 

 

 

 

Well Permit number (for each well)

4/ Details of public supply

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Public Water Used for: Domestic, Fire Protection, Process Water,

 

Other

Name of Public Community Water System

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Public Water System ID number (PWSID)

The Public Community Water Supplier hereby concurs with the proposed installation and the submission of

this application

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Reviewed by:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Authorized representative:

 

Title

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature

__________________________________

Date

 

/

 

/

 

Phone (

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5/ Name of Local Administrative Authority

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Board of Health, Plumbing Sub-Code Official, Exempt (Reason

 

 

 

 

 

)

Name

 

 

 

 

Phone (

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6/ Applicant’s Signature

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature_______________________________________________ Date

INSTRUCTIONS - Complete both Page 1 of 2 and obtain the signature / approval of the Public Water System

and mail to the Department at the above address & Owner of the Public Water System with:

A Drawing showing; the facility layout, surrounding streets, location of unapproved water supply and Public Water Service Connections, location of meters and backflow preventer valve(s) & a schematic of sufficient detail to show the installation of each backflow preventer valve.

A Check made payable to; Treasurer State of New Jersey in the amount of $150.00 shall accompany the application to the Department.

This Form shall be used to modify an existing Physical Connection Permit.

Initial Physical Connection Permit Application

Duplex Form do not reproduce on separate pages

Page 2 of 2 02/13

 

 

 

 

 

 

Physical Connection Permit Number

 

-WPC

 

 

List the Type, Size, Location of Public Water System Service Connections & Backflow Preventer Valve(s) that you are applying for:

 

 

Service

 

Backflow Preventer

 

Location :

 

Protected By-Pass / Detector Check

1.

 

 

Domestic Size

 

 

D.C.V.A.

Size

 

 

At:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fire inch

 

 

R.P.Z. inch

 

 

 

 

Protected By-Pass

 

Size

 

 

Detector Check

 

Size

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Domestic Size

 

 

D.C.V.A.

Size

 

 

At:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fire inch

 

 

R.P.Z. inch

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Protected By-Pass

 

Size

 

 

Detector Check

 

Size

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Domestic Size

 

 

D.C.V.A.

Size

 

 

At:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fire inch

 

 

R.P.Z. inch

 

 

 

 

Protected By-Pass

 

Size

 

 

Detector Check

 

Size

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Domestic Size

 

 

D.C.V.A.

Size

 

 

At:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fire inch

 

 

R.P.Z. inch

 

 

 

 

Protected By-Pass

 

Size

 

Detector Check

 

Size

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Domestic Size

 

 

D.C.V.A.

Size

 

 

At:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fire inch

 

 

R.P.Z. inch

 

 

 

 

Protected By-Pass

 

Size

 

Detector Check

 

Size

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6.

 

 

Domestic Size

 

 

D.C.V.A.

Size

 

 

At:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fire inch

 

 

R.P.Z. inch

 

 

 

 

Protected By-Pass

 

Size

 

Detector Check

 

Size

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Domestic Size

 

 

D.C.V.A.

Size

 

 

At:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fire inch

 

 

R.P.Z. inch

 

 

 

 

Protected By-Pass

 

Size

 

Detector Check

 

Size

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8.

 

 

Domestic Size

 

 

D.C.V.A.

Size

 

 

At:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fire inch

 

 

R.P.Z. inch

 

 

 

 

Protected By-Pass

 

Size

 

Detector Check

 

Size

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Domestic Size

 

 

D.C.V.A.

Size

 

 

At:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fire inch

 

 

R.P.Z. inch

 

 

 

 

Protected By-Pass

 

Size

 

Detector Check

 

Size

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Domestic Size

 

 

D.C.V.A.

Size

 

 

At:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fire inch

 

 

R.P.Z. inch

 

 

 

 

Protected By-Pass

 

Size

 

Detector Check

 

Size

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11.

 

 

Domestic Size

 

 

D.C.V.A.

Size

 

 

At:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fire inch

 

 

R.P.Z. inch

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Protected By-Pass

 

Size

 

 

Detector Check

 

Size

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12.

 

 

Domestic Size

 

 

D.C.V.A.

Size

 

 

At:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fire inch

 

 

R.P.Z. inch

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Protected By-Pass

 

Size

 

 

Detector Check

 

Size

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you are applying for more than 12 devices please copy this page, list the additional devices and include with you application.

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This PDF form requires particular information to be entered, hence you should definitely take the time to type in what is requested:

1. Before anything else, while filling out the preventer, start with the form section that includes the next blanks:

Writing segment 1 of Duplex

2. Your next stage is to submit all of the following blanks: Applicant Details, Cross Connection Exists or, Domestic, Fire Protection, If from Wells number of wells Well, Other, Process Water, Board of Health Plumbing SubCode, Exempt Reason, and Name Phone Applicants Signature.

Completing section 2 of Duplex

3. The next step should also be pretty easy, Initial Physical Connection Permit, Physical Connection Permit Number, Domestic Size, DCVA Size, Fire inch, Domestic Size, Fire inch, Domestic Size, Fire inch, Domestic Size, Fire inch, Domestic Size, Fire inch, RPZ inch, and Protected ByPass Size - these form fields has to be filled out here.

The right way to fill in Duplex step 3

4. This paragraph comes with the next few empty form fields to type in your specifics in: Fire inch, Domestic Size, Fire inch, Domestic Size, Fire inch, Domestic Size, Fire inch, Domestic Size, Fire inch, Domestic Size, Fire inch, Domestic Size, Fire inch, RPZ inch, and Protected ByPass Size.

Completing segment 4 of Duplex

5. To wrap up your form, the final part incorporates several additional fields. Typing in Domestic Size, DCVA Size, Fire inch, RPZ inch, Protected ByPass Size, Detector Check Size, and If you are applying for more than should finalize everything and you can be done quickly!

Find out how to complete Duplex portion 5

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