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Water Line Disinfection Application

Complete this form to apply for water line disinfection.

Contractor must meet with Water Services group to discuss disinfection method, sampling and testing. Disinfection procedure will not be approved without the pre-application documentation outlined below.

This form must be submitted 3 weeks in advance.

Company Name:

Application Date:

Representative:

Company Billing Address:

Date Planned for Chlorination of Main:

Contact Person:

Contact Phone Number:

Alternate Contact Person:

Alternate Contact Phone Number:

Email:

Pre-Application Check List: (Choose one)

Newly Constructed Lines

Replaced Line

The following documents are required:

Disinfection Procedures

Pressure Test Results Attached

Site Plan Drawing Attached (clearly mark, pipe that is being chlorinated, injection and test points)

MSDS Sheet of Chlorine Product

Disinfection Procedure File Upload:

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Pressure Test Results File Upload:

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Site Plan Drawing File Upload:

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MSDS Sheet of Chlorine Product File Upload:

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Signature: (Sign using your mouse or finger)

Clear

The following question is for office use and do not require your answer.

Please click the "Submit" button to submit your application.

Approved By:

Disinfection Completion Date:

Work Order Number:

Bateriological Sample Results:

Positive

Negative

Comments: