Professional Documents
Culture Documents
Submit to:
New Hampshire Department of Environmental Services
Drinking Water and Groundwater Bureau
29 Hazen Drive, P.O. Box 95
Concord, New Hampshire 03302-0095
Telephone: (603) 271-2513 Fax: (603) 271-5171
DWGBInfo@des.nh.gov
www.des.nh.gov/dwgb/capacity/
Prepared by:
NHDES-W-03-032
PWS NAME ________________________________
TOWN
________________________________
DATE____________
Build-out
max
gpd
Domestic Disposal
Individual unit septic systems with subsurface tanks and leachfields
Communal or shared septic system
For either individual or community septic, does any part of the system required
pumping? Y/N ____
Local, regional or municipal sanitary sewer system.
NHDES-W-03-032
Date
for each type / size of pipe, example, 200 ft of 3 PVC pipe installed ~ 1970, and 300 feet of 1 black polyethylene pipe in ~1980. If more lines are
needed, make a copy of this page.
Condition Score (5) Very Poor; (4) Poor; (3) Fair; (2) Good; (1) Excellent.
Impact Score: (1) Catastrophic; (2) Major; (3) Moderate; (4) Minor; (5) Insignificant.
Probability of Failure (5) Imminent; (4) Very likely; (3) Likely; (2) Unlikely; (1) Highly Unlikely
2014-11-10
NHDES-W-03-032
Date
NHDES-W-03-032
7. Any subcontracted services.
NHDES-W-03-032
NHDES-W-03-032
FOR
PREVIOUS YEAR
NHDES-W-03-032
PART D. REVENUES
Section 1: Revenue
Make copies of this page for projected revenues and expenses for future years.
Actual
Last
Year
Operating Revenues
Budget
Current
Yr
Projecte
d Next
Yr
Other Revenues
Interest Earned on Deposits
Other (describe)
TOTAL REVENUES
Surplus or (Deficit)
Total Revenues minus Total Expenses
Section 2: Revenue
Water Use per Billing
Period (gallons)
[flat fee or insert
ranges]
Average
Number
of
Customer
s
Monthly
Minimu
m
Charge
Gallons
include
d in
minimu
m
charge
Flat Fee
Residential
Commercial
Cost
per
1000
Gallons
Notes
NHDES-W-03-032
Date of
Loan
Amount
FOR
Interes
t
Rate
Current
Balance
Term
PREVIOUS YEAR
____________
B. What is the total amount of billed metered water (does not include any
water that was not metered, not billed, or both)?
____________
____________
D. What is the total percent of water being distributed into the water
system which is not billed or metered? (Divide Row C by Row A, then
multiply by 100)
____________
NHDES-W-03-032
__________________________________
Water System Owner or Representative
____________
Date
(example)
For Community Water Systems
Pursuant to NH Administrative Rule Env-Dw 602.08
Capacity Assurance for New or Existing Public Water Systems
Initial and Continuing Disclosure
This property is served by a public water system (PWS) and is subject to regulation under the
federal and state Safe Drinking Water Acts. Revenues for operation and maintenance of the
water system are derived entirely from the users. You are hereby notified that your Annual Water
Rates shall be as follows:
Connection Fee
$ ______________
Usage charge (ex. per 1000 gal or per 100 CF). All new community water systems are required to
charge based on usage. The usage rate may be charged on top of a base rate. The usage rate
must stay the same or increase with volume consumed.
Minimum base charge
_________________ (ex. 0 to 1,000 gal)
_________________ (ex. 1,001 gal and higher)
$ ______________
$ ______________
$ ______________
Please note that the PWS owner or governing body reserves the right to increase (or decrease)
the above water rates up to _____% per year, as necessary to meet the water system expenses.
Copy of the water system Business Plan is available by contacting the Owner at:
_____________________________________________
General information on drinking water regulations and compliance requirements applicable to this
water system are also available from:
NH Department of Environmental Services Drinking Water and Groundwater Bureau
(603) 271-2513, dwgbinfo@des.nh.gov or www.des.nh.gov/dwgb/
and
US Environmental Protection Agency, Office of Ground Water & Drinking Water
Safe Drinking Water Hotline (800) 426-4791 or www.epa.gov/safewater/