3900-PM-BSDW0254b Rev. 2/2013 COMMONWEALTH OF PENNSYLVANIA Module 1 DEPARTMENT OF ENVIRONMENTAL PROTECTION BUREAU OF SAFE DRINKING WATER

Date Prepared PUBLIC WATER SUPPLY MODULE 1 – COMPLETENESS REPORT A. GENERAL INFORMATION

Date Revised Permit No. (For Department Use Only)

Design Engineer and Firm: Public Water System: PWSID: Location of Project: Municipality County Description of Project:

Justification of Project (Describe the public health and/or economic benefits of the project):

B. DOCUMENTATION REQUIRED (109.503; PWS Manual, Part II, Sections I.B.3.a. and III.D.2.) 1. Have two (2) copies of both the General Information Form (1300-PM-BIT0001) and the Public Water Supply Permit Application Yes No (3900-PM-BSDW0002), including all appropriate signatures and seals, been submitted? a. If yes, are the applications forms signed and sealed by all appropriate Yes No parties? 2. Is a check made payable to the Commonwealth of Pennsylvania included Yes No for all appropriate fees, see 109.503(c)? 3. Have two (2) copies of the design engineer’s report, signed and sealed by a licensed professional engineer registered to practice in the Yes No Commonwealth of Pennsylvania, been submitted? 4. Was there a pre-application meeting with DEP and the project applicant? Yes No a. If yes, does the permit application include all items determined to be Yes No necessary following the pre-application meeting? 5. Does the engineer’s report include all applicable items specified in Part II Yes No of the Department’s Public Water Supply Manual? a. A description of the existing water works and an identification of the Yes No municipality or area served. b. A description of the nature and extent of the area to be served, provisions for extending the water supply system to include additional areas, and an appraisal of the future requirements for service, including Yes No existing and potential industrial, commercial, institutional and other water supply needs. c. Justification of the project, including a discussion of alternatives and Yes No the reasons for selecting the one recommended.

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d. Water use data, including a description of the population trends, present and projected water consumption, and present and/or estimated Yes No yield of sources of supply. e. Fire flow requirements. Yes No f. Sewerage facilities, including the location of existing onlot or municipal Yes No sewage treatment facilities which may affect the quality of the sources. g. Information about proposed sources of water. Yes No h. Information about proposed treatment processes. Yes No i. A description of the project site. Yes No j. Waste disposal, including a discussion of various wastes from the water treatment plant, their volume, proposed treatment and points of Yes No discharge. k. A description of the character of the soil, groundwater conditions and Yes No foundation conditions. l. A summary of planning for future needs and services. Yes No m. Does the engineer’s report include a plan for keeping existing waterworks facilities in operation to provide a safe, potable water supply Yes No at all times during construction activities? 6. SIMULTANEOUS COMPLIANCE (109.602) N/A a. Has a formal assessment been made of new project-related simultaneous compliance issues, which includes identifying the Yes No anticipated impact on specific parameters? a. Have applicable guidance manuals been reviewed as part of this Yes No assessment? b. Is an assessment summary document discussing the above-mentioned Yes No topics included with the submittal documentation? c. Will assessment-identified problem areas be tracked, and will a Yes No sampling plan be implemented, that will provide both baseline (pre- process change) and post-change data? 7. Have two (2) copies of the hydrogeologic report, signed and sealed by a professional geologist licensed by the Commonwealth of Pennsylvania, Yes No N/A been submitted? 8. Does the hydrogeologic report include all applicable items as specified in Yes No N/A Part II of the Department’s Public Water Supply Manual? a. Description of the hydrogeologic setting and conceptual model of the Yes No project area. b. Stratigraphic logs for each well drilled clearly showing static water Yes No level, all water-bearing zones and a description of all geologic formations. c. As-built cross sections for each well demonstrating well construction Yes No details. d. A copy of the completed Water Well Inventory Report. Yes No e. Aquifer test data and supporting drawdown and recovery graphs. Yes No f. Aquifer characteristics and all calculations. Yes No g. Dependable source yield with justification. Yes No h. Other information that describes the hydraulic characteristics of the Yes No aquifer and demonstrates the suitability of the proposed source. 1 - 2 3900-PM-BSDW0254b Rev. 2/2013 Module 1

i. Proof of the supplier’s ability to control the Zone I wellhead protection Yes No area. j. Information for springs, including geological information and Yes No construction details. k. All sample results (i.e., new source sampling, Microscopic Particulate Yes No Analysis (MPA), SWIP monitoring, etc.) l. Discussion of other applicable permits or approvals which may be Yes No required (i.e., proof of resolution of PNDI conflicts). m. Description of potential impacts that pumping of the new source will, or could have, on adjacent wetlands, surface waterbodies, private or public Yes No wells, springs or other adjacent surface and subsurface water features. 9. Have two (2) copies of the business plan been included if the submittal is Yes No N/A for a new community public water supplier? Does the business plan include the following minimum items as specified Yes No in 109.503(a)(3)? a. Facilities Plan b. Management Plan c. Financial Plan 10. Please indicate which of the following modules, in addition to this Module, have been included. Please ensure that two (2) copies are submitted for each module. Module Number Title 1 Completeness Report Yes No N/A 2 General Design Data Yes No N/A 3A Groundwater Sources Yes No N/A 3B Surface Water Sources Yes No N/A 4 Pretreatment Yes No N/A 5 Suspended Solids Contact Units Yes No N/A 6 Softening Yes No N/A 7 Filtration Yes No N/A 8 Disinfection Yes No N/A 9A Iron and Manganese Removal Yes No N/A 9B Nitrate Removal Yes No N/A 10 Corrosion Control Yes No N/A 11 Organics Removal Yes No N/A 12 Chemicals and Chemical Handling Yes No N/A 13 Pumping Stations Yes No N/A 14 Reservoirs, Elevated Tanks, Standpipes and Pressure Tanks Yes No N/A 15A Distribution Systems Yes No N/A 15B Bulk Water Loading Station Yes No N/A 16A In State Bottled Water Systems Yes No N/A 16B Out-of-State Bottled Water Systems Yes No N/A 17 Bulk Water Haulers Yes No N/A 18 Vended Water Systems Yes No N/A 1 - 3 3900-PM-BSDW0254b Rev. 2/2013 Module 1

19 Retail Water Facilities Yes No N/A Other

C. REQUIRED GRAPHIC DATA (109.503; PWS Manual, Part II, Section I.B.3.b.) 1. Have two (2) copies of the designer’s plans and specifications been Yes No submitted? 2. Does the front cover or flyleaf or first page of each set of drawings and specifications bear the signature and embossed seal or reasonable Yes No facsimile of the licensed professional engineer, registered to practice in the Commonwealth of Pennsylvania, by or under whom prepared? 3. Does each subsequent page or drawing bear an embossed seal or Yes No reasonable facsimile of such seal? . Please indicate which of the following have been included as part of the plans: a. Topographic maps Yes No b. General layouts Yes No c. Plan views Yes No d. Elevations Yes No e. Sections and supplementary views Yes No Locations of existing and potential sources of pollution including f. Yes No associated geographic latitude and longitude of all sources g. Datum used Yes No h. North point Yes No i. Boundaries of municipalities Yes No j. Water districts and areas to be served Yes No k. Complete topography of drainage area and sites Yes No l. Locations, dimensions and elevations of structures and piping Yes No m. Locations and outline form of equipment Yes No n. Water levels and flood levels Yes No Locations of test borings and wells with associated latitudes and o. Yes No longitudes p. Graphic scale in feet Yes No q. Suitable title of applicant, including date Yes No r. Zone I Wellhead Protection Area Yes No

D. SPECIFICATIONS (109.503; PWS Manual, Part II, Section I.B.3.c.) 1. Are complete detailed specifications supplied for the proposed project? Yes No

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E. CODES (Chapter 109, Subchapter F. Design and Construction Standards) Will the proposed facilities meet the requirements as listed in DEP's Public 1. Yes No Water Supply Manual, Section I.D.? Will all materials and chemicals that come in contact with, or affect the 2. quality of, the water be certified for conformance with ANSI/NSF Standards Yes No 60 and 61, as applicable? If not, explain why:

F. OTHER STATE APPROVALS OR COORDINATION Has application or coordination been made: 1. to DEP for a Water Allocation Permit? Yes No N/A to the Public Utility Commission for a Certificate of Public 2. Yes No N/A Convenience? 3. to DEP for an NPDES Permit? Yes No N/A

4. to DEP for an Encroachment Permit? Yes No N/A to DEP for an Earth Disturbance Permit (erosion and sedimentation 5. Yes No N/A control, Chapter 102)? (109.503(a)(1)(iv)) 6. to DEP for a Residual Waste Processing Permit? Yes No N/A

7. to DEP for a Disposal Facility Permit? Yes No N/A

8. to DEP for an Air Quality Operating Permit? Yes No N/A

9. to the Pennsylvania Historical and Museum Commission? Yes No N/A

10. to appropriate river basin commission? Yes No N/A

11. to resolve the Pennsylvania Natural Diversity Inventory (PNDI)? Yes No N/A to determine and if applicable, resolve potential conflict with 12. Yes No N/A Pennsylvania Natural Diversity Inventory (PNDI)? to obtain Underground Injection control (UIC) permit from EPA, if 13. Yes No N/A applicable? 14. to obtain Fish and Boat Commission approvals, if applicable? Yes No N/A Is documentation to verify compliance with Act 67/68municipal and 15. county notification requirements submitted? (applicable to only new Yes No N/A public water supply)

INNOVATIVE TREATMENT TECHNOLOGY (109.507; PWS Manual, Part II, G. Section I.C.)

1. Does this project involve innovative treatment technologies? Yes No

2. Has the treatment process been thoroughly tested in full-scale comparable Yes No installations under competent supervision? If yes, please attach report.

3. Has the treatment process been thoroughly tested in a pilot plant operation for a sufficient time to ensure the technology provides drinking water which meets Yes No all applicable drinking water standards? If yes, please attach report.

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INFORMATION DESCRIBING NEW SOURCES (109.503(a)(1)(iii); PWS H. Manual, Part II, Section III.)

1. Does this project involve a new source of supply? Yes No

2. If yes, are the following minimum items included in this application? Yes No Yes No a. Comprehensive sanitary survey (see Module 2)

b. Hydrogeologic report (for groundwater sources), including all details provided Yes No in Section A of this Module Yes No c. New source sampling results (see Module 3) Yes No d. An evaluation of the quantity of raw water from each new source Yes No e. Zone I delineation

I. ORIGINAL SEAL AND SIGNATURE OF PROFESSIONAL ENGINEER

1. Signature of Professional Engineer

2. Professional Engineer’s Seal

SEAL

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