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#&XX%&&#&X&X&(+&Date:_________________#&&(+#&(+&#X&(+#&(+X  TCEQPWSIdentificationNo.*:______________________CCNNo.orApplicationNo.**:____________________________________ .b WaterSystemName:__________________________________________________________________________________________   WaterSystemOwner:________________________________________TypeofEntity:______________________________________  Address:____________________________________________________________________________________________________ ,` ________________________________________________________Phone:()_____________   ResponsibleOfficial:____________________________________Title:______________________________________________  ***County(systemlocation):________________________________#&&(+T#&(+&#X&(+#&(+XMechanism&SourceofFinancing_________________________ *^  SubdivisionSec.,Phase,Unit,etc._#&&(+#&(+&#X&(+#&(+X__#&&(+#&(+&#X&(+#&(+X______________________________________________________________________________   Engineer:_________________________________RegistrationNumber:________________EMail:___________________________#&&(+ #&(+&#X&(+K #&(+X ~  FirmName:________________________________________Phone:(_____)__#X&(+ #&(+X#&&(+q #&(+&ԀFax:(______)____________#&&(+ #&(+&#X&(+| #&(+X ( \  FirmAddress:_________________________________________________________________________________________________     '  eXX'*#&&(+& #Ԁ   IfnoPWSNumberexists,theownermustsubmitabusinessplan,ifrequired,inaccordancewith290.39(f)and(g). 0 d      0hX  eX00   ** 0%%IfaCCNisrequiredandaCCNdoesnotexist,anacceptableapplicationtoobtainaCCNnumbermustbemadebeforeaprojectsubmittalcanbe    technicallyreviewed.Inaddition,ifasubmittalisforaprojectlocatedoutsidetheCCNarea,aCCNamendmentapplicationmustbesubmittedbefore   aprojectmaybereviewedforconstructionapproval.Pleasereferto30TACChapter291foradditionalinformationregardingCCNs.&(+&#X&(+h #&(+X R %% "Ifthisisanew(proposed)system,youmustattachthefollowingwiththissubmittal: b  0  Attachalistofallwaterutilitieswithinmileoftheproposedserviceareaboundaries @%%  (7x3"3"  3q273  0    Copiesofformalapplicationsforservicefromeachofthefollowing:3q݌%% Ќ    0 h anymunicipalityifthesystemiswithinitsETJ;`h%h% 0  0h%%anydistrictorotherpoliticalsubdivisionwhosecorporateboundariesarewithinmileoftheproposedserviceareaboundaries >h%h% ";"  ;0  273  0h%%  anyotherwaterserviceproviderwhosecertificatedserviceareaboundaryiswithinmileoftheproposedservicearea  boundaries;݌^h%h% Ќ    0  Documentationthatallapplicationrequirementsincludingpaymentoffeeswerecompliedwith.<%% 0  Copiesofwrittenresponsesfromeachoftheentitieslistedabove.%% 0  Businessplan.Thebusinessplanfinancialrequirementsfornoncommunitywatersystemsmustconfirmcapitalavailabilitytoconstruct \ thesystemaccordingtoTCEQrequirements.Thiswouldconsistofabalancesheetthatshowsliabilitiesaswellasassets,notjustabank : confirmationofadepositaccount.Alternatively,iftheprojectisbeingconstructedwithloanfunds,thenaloancommitmentletterfrom  thelenderspecifictothatprojectwillsuffice.Z %% 0  Justificationforconstructingaseparatesystem(unlessnoneoftheentitieslistedaboveexist)8!%%  %(7xx #X&(+#&(+X#&&(+b#&(+&ԀTCEQCoreDataForm(No.10400) " TypeofProject(pleasechecktheappropriateboxes).Submitasealedengineeringreportthatincludesthenumberofconnectionstobe 6$ served. %   0 h DistributionSystemModifications0 h%h%0  % %0x % %0x%x%SurfaceWaterTreatmentPlant,New#X&(+##XX#&X&(+&0 %%#&&(+#&(+&#X&(+#&(+X0" % %#X&(+#&(+X#&&(+e#&(+&V&"%"% 0 h StorageCapacityModifications#X&(+#&(+X#&&(+A#&(+&0 h%h%0  % %0x % %#&&(+##X&#XX&(+X0x%x%ModificationofSurfaceWaterTreatmentPlant#X&(+#&(+X#&&(+#&(+&4'%% #X&(+] #&(+X#&&(+ #&(+&0 h PressureMaintenanceFacilitiesModifications x 0h%h%ProposedInnovativeProcessStudy(%% ***WaterWellConstruction,Proposed#X&(+!##XXB!#&X&(+&   x    (    T) ***Wellcompletiondataonpreviouslyapprovedwell#X&(+|"#&(+X#&&(+"#&(+&0 x #&&(+##&(+&#X&(+m##&(+X#X&(+?$#&(+X#&&(+##&(+&0x%x%RequestforRuleException2*%% ***GroundWaterTreatmentPlant,New#X&(+$#&(+X#&&(+$#&(+&0  0x % %0x%x%PreliminaryEngineeringReportw/oplans#&&(+%##X&%#XX&(+X+%% #X&(+&#&(+X#&&(+&#&(+&#&&(+Q'#&(+&#X&(+'#&(+X0  0h%%DisinfectionFacilitiesorOtherModifications#&&(+'#&(+&#X&(+'#&(+XԀ0xh%h%#X&(+(#&(+X#&&(+j(#&(+&0x%x%Tex.WaterDev.BoardProj.No.__________________________#&&(+E)#&(+&#X&(+)#&(+XR,%% #&&(+)#&(+&#X&(+*#&(+X0  0h%%0h%h%0 %%0p  % %0 p %p %0  % %0x % %00x%x%PilotStudyforInnovative/AlternativeSystem(Anytreatment 0- processnotdescribedinCh290orloadingratesgreaterthan . allowable)P /%% 0  0h%%0h%h%0 %%0p  % %0 p %p %0  % %0x % %00x%x%Other(Pleasedescribe)________________________________ . 0%% _______________________________________________________________________________________________________________ ! 1   #&&(+{*##X&*#&X#X&E.#L  M  L  M  L  M  L  M  L  M  W:6 >FN!V$&)hXWL  M  L  M  MX***Pleasereferto#XMx/#L  M  4Y 3K   5  L  M  J  MXalistofcountieswherethereisanelevatedriskofRADIONUCLIDESinthegroundwater.JD0  MXXM#XXXMXu0#6/K/   7 P&0L  M  CEUS.,LXXXXԀUS.,CE.,1#XXXLX1#L  M  L  M  #XXX#1#MXThewebsitealsohashelpfulinformation ""3 regardingtheradionuclidetestingrequiredinthesecounties.#XM2#L  M  MXԀ#XM[3#L  M  XXM(+X ##4   #MM(+3##XM3#  &X&(+&  -  IFTHISSUBMITTALISAREVISIONOFPREVIOUSLYSUBMITTEDPLANS,PLEASEENTERTHEASSIGNEDTCEQLOG %L$6 NUMBER:____________________.Pleasecall(512)2394691ifyouhavequestionsregardingthisform.Yourcooperationwillhelpus %$7 providebetterservice. րAdditionalhelpfulinformationandrulesareavailableatourwebsite: l&%8 4   j      r   "  z    *       #&&(+4##X&c4#L  M  L  M  L  M  L  M  `:6 >FN!V$&)6X!V$X`L  M  L  M  XXM(+XԀ#MM(+28##XMQ8#L  M  4O K   5  L  M  J  XXM(+XRulesavailableon[planrevwebsite]J.9_  #MM(+_9#MXXM#XXXMX~9#NXXXX68K8 _  7 9L  M  #NQXNX::#NbNQ#XNb|:#M(+X '&: #MM(+9;##XM{;#  9XX&(+X7@Iherebycertifythattheaboveinformationis,tothebestofmyknowledge,trueandcorrect. )R(<    j      r   "  z   #&&(+<#&&SignedP.E.Sealbelow:#&&=#&(+&#X&(+4<#&(+X -   "  r*)>    j      r  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