Connecticut State Department of Public Health

Forms and Applications

Drinking Water Section standard forms and applications:

Annual Statement

Connecticut General Statute (CGS) Sec. 25-33 requires each water company to annually file with the Department of Public Health (DPH) a written statement containing certain information related to the water system. This information is to be provided in a form prescribed by the Commissioner. In addition, pursuant to Section 19-13-B102(r) of the Regulations of Connecticut State Agencies (RCSA), all community water systems are required to provide a continuously available emergency telephone number to the DPH on or before January 1 of each year. To assist public water systems in complying with these reporting requirements, the Drinking Water Section (DWS) has developed the Public Water System Annual Statement form.

General Application

This general application form must be completed & submitted to the Drinking Water Section along with any project or application that requires an approval or permit from the Department.

Public Water System General Application For Approval Or Permit | Adobe PDF Version | Microsoft Word Version

Water Main Application and Standards

The Water Main Design and Construction Guidelines and Water Main Application are provided in the interest of facilitating the approval process for federally or state funded projects such as Drinking Water State Revolving Fund and STEAP grant projects that may include water main replacements or installations. Discretion in the application of these guidelines is allowable except as required by regulation. For routine distribution water main installations that do not require approval from the Department prior to construction, it is recommended that the guidelines be utilized during design and construction except as required by regulation.

Public Water System Notification Form 

A notification form to assist public water systems in reporting violations and incidents is now available and should be utilized to help you confirm that you are in compliance with the reporting requirements of Sections 19-13-B46 and 19-13-B102(h) of the Regulations of Connecticut State Agencies. It is important, however, to note that submitting this form is not a substitute for reporting emergencies promptly via telephone.

Sampling Site Plan

Public Water System sampling site plans for disinfection byproducts (TTHMs & HAA5), disinfection residuals, total coliform, physical parameters, lead and copper tap sampling and asbestos must be submitted to the DWS whenever there are proposed changes to the plan.  The Sampling Site Plan – Sampling Point Inventory form must be completed fully and submitted to the DWS along with a map depicting the location of all sampling points. Completed forms and maps may be mailed or sent electronically to the following e-mail address: DWDCompliance@ct.gov

Public Water System Contact Update Form

The Public Water System Contact Update form is used to add, change or remove individual contacts associated with a Public Water System. The Drinking Water Section requires all Public Water Systems to designate one Administrative Contact and a minimum of one Owner and/or one Legal Contact.  Systems failing to update this contact information when changes are necessary may be in violation of Section 25-33 of the Connecticut General Statutes and may be subjected to enforcement action and civil penalties.

Public Water System Contact Update Form

Water Treatment Plant Classification Form

Water treatment plants must be classified according to points assigned to each plant
based on the Association of Boards of Certification system, pursuant to Section 25-32-8 of the Regulations of Connecticut State Agencies. The regulation requires that the classification form be provided by the Department of Public Health (DPH), filled in by the system and the contents verified by the DPH.  The class of the treatment plant determines the class of the certified operator required to operate the plant. Treatment plants are classified based the sum of points assigned for the following treatment plant and water system features: 1) Plant Size, 2) Water Supply Source, 3) Treatment Unit Processes, 4) Residual Disposal, and 5) Facility Characteristics. 

Water Treatment Plant Classification Form    

Public Water Supply Well Site Approval 

Below is the application for a Public Drinking Water Supply Well and other related information. Public Water System Well Site Approval Application

Filter Backwash Recycling Rule

Introduction:  On June 8, 2001, the Filter Backwash Recycling Rule (FBRR) was published in the Federal Register and on April 22, 2003 the Regulations of Connecticut State Agencies (RCSA) were amended to adopt this rule. The FBRR applies to public water systems that use surface water or ground water under the influence (GWUI) of surface water, apply conventional or direct filtration treatment, and recycle spent filter backwash, thickener supernatant, or liquids from dewatering processes. Public water systems that are required to comply with the FBRR requirements must ensure that the applicable recycle notification and recordkeeping forms are completed and retained on file for review and evaluation by the Department.

Operator Verification Form

All Community and Non-Transient Non-Community Public Water Systems are required to notify the Drinking Water Section (DWS) of the certified operators designated for each Treatment Plant, Distribution System and Small Water System. The Operator Verification Form is to be submitted by the Public Water System to notify the DWS of any designations or changes. This form should be submitted prior to or immediately after any change so that the system is not in violation of operator certification regulations. Certified Operators should ensure that this form is submitted if they are no longer the operator for a system so that the DWS does not continue to hold them responsible for the system’s operation. 

 Public Water System Screening Form

This form is used to determine if a proposed project or a change in operation at an existing facility will result in the creation of new public water system or change the classification (Community, Non-Transient Non-Community, or Transient Non-Community) of an existing public water system. Working in cooperation with the Connecticut Environmental Health Association (https://www.cteha.org/ ), the form has been modified to address common questions, capture some additional information and include local health sign off (similar to well permit exception form).

Source Abandonment Permit Application

This application is for a permit under Section 25-33k of the Connecticut General Statutes for a water company to abandon any existing or future source of water supply. The applicant must provide the department with sufficient information to verify that the source will not be needed for present or future water supply, is consistent with the water company’s water supply plan, if so required, and will not be needed by the company in an emergency. This form is designed to supply the department with the basic information necessary to evaluate the permit request. Applicants are encouraged to provide any other information they feel will lead to a full understanding of the proposed abandonment. The applicant will be notified if additional information is required.

Sale of Excess Water Permit Application

This application is for a permit under Section 22a-358 of the Connecticut General Statutes for a public water system to sell water reserves in excess of those required to maintain an abundant supply of water to customers in its service area. The applicant must provide the department with sufficient information to verify that the water proposed for sale is in excess of that required to meet their system needs. This form is designed to supply the department with the basic information necessary to evaluate the permit request. Applicants are encouraged to provide any other information they feel will lead to a full understanding of the proposed sale.  The applicant will be notified if additional information is required.

Operator Contact Update

It is the responsibility of the certified operator to keep all contact information up to date with the Department of Public Health.  Submit the following form to the Drinking Water Section if there is a change in your address/contact information to ensure you receive all important State mailings including certificate renewal applications. 

Bulk Water Hauling Notification

The following notification form should be completed and submitted to the Department after a Public Water System (PWS) hauls in bulk water. Note that if bulk water hauling is required due to an emergency as defined in Section 19-13-B46 of the Regulations of Connecticut State Agencies, a Notification Form to Confirm Compliance with Sections 19-13-B46 & 19-13-B102 of the Regulations of Connecticut State Agencies (RCSA) must be completed and submitted.

Certification Form for Consumer Notification of Lead Tap Monitoring

All Community and Non Transient Non Community water systems must provide a notice of lead tap water results to the occupants of the residence or facility in which the samples were collected. This notice must be delivered to the consumer as soon as possible but no later than 30 days after the system learns of the tap water results. Within three months following the end of the monitoring period, the system will also be required to certify to the state, delivery of these results. Click on the following link for an approved certification template:

Department of Education School Water System Project Evaluation Form  

This form should be submitted to the Department of Education along with a copy to the Department of Public Health – Drinking Water Section (DWS). The purpose of this form is intended to evaluate whether or not additional information regarding the water supply system at the school must be submitted to DWS for review prior to construction of any school renovations or increases in occupant capacity.

Certification of Completed Water or Treatment Works Construction/Installation

This certification letter must be completed and signed by the Public Water System’s administrative official, his or her designated representative, or certified operator and submitted to the Drinking Water Section (DWS) after construction or installation of a DWS approved water or treatment works project is completed.

Water Supply Plan Updates
Application for a Well Permit Exception

The Regulations of Connecticut State Agencies (RCSA) prohibits a local director of health from issuing a well drilling permit at residential premises where the water will be used for human consumption, or at non-residential premises where the water may be used for human consumption, when a community water system is deemed available within two hundred feet from the parcel's boundary. In some circumstances, an exception to this regulation may be granted. This application is intended to provide the Drinking Water Section with the information necessary to determine whether such an exception may be issued to the Director of Health. Although the Director of Health is the applicant to the Department, the application has streamlined the process by allowing the affected parcel's owner to gather the relevant information required for Department review.

Public Water Supply Capacity Reporting Forms

    Water Quality Monitoring and Reporting Forms

    Every Public Water System is required to submit water quality data to the CT Department of Public Health for compliance purposes. This data is required to be submitted in a format and manner prescribed by the department. All Standard Water Quality Monitoring and Reporting forms are provided by the department to satisfy this requirement. These forms have been listed below and must be used, which will facilitate the submittal of all possible water quality compliance data. 

    You will need Microsoft Excel to View these files, if you do not have Microsoft Excel you can download the FREE Microsoft Excel Viewer here You must email the following water quality forms to the Drinking Water Section for processing: 
    1. Monthly Treatment Effluent Monitoring and Reporting Form 
      Surface Water Treatment Distribution System Disinfectant Residual Monitoring Form 
    2. Surface Water Treatment Entry Point and Distribution Chlorine Residual Monitoring Form 
    3. Surface Water Treatment Individual Filter Effluent Turbidity Monitoring and Reporting Form 
    4. Surface Water Treatment Combined Filter Effluent Turbidity Monitoring and Reporting Form 
    5. Chlorine Dioxide and Chlorite Monitoring and Reporting Form 
    6. Chlorine Dioxide Monitoring and Reporting Form – Exceedance Attachment 
    7. Total Organic Carbon Monitoring and Reporting Form
    8. Ground Water Rule Residual Disinfectant Compliance Monitoring Form 
    Please follow this procedure: 
    1. Use the following email address – drinking.water@ct.gov This is the same address currently used for all electronic reporting. 
    2. In the subject line of the email indicate that there are forms attached. 
      Keep the Monthly Treatment Effluent Monitoring and Reporting Form(s) separate from the rest of the forms. In other words, separate emails. 
    3. At this time do not attach more than eight (8) forms per email. 
    4. Name your forms clearly and uniquely. 
    5. Data on these forms will be manually data entered so you will not receive a processed receipt. You will receive an acknowledgement that a form was received. If there are any errors on the form you will be notified. 
    6. Do not mix forms and edit text files in the same email.