Permit No. _______________

CSD Service Area

Big Bear Area Regional Wastewater Agency

Recycled Water Service Application (2008)

1. PROJECT NAME:
2. PHYSICAL LOCATION:
APN # - If available
3. CONTRACTOR’S NAME:
4. MAILING ADDRESS:
5. CONTACT INDIVIDUAL/TITLE:
6. PHONE NUMBER:
7. MOBILE PHONE/PAGER:
8. FAX NUMBER:
9. LOCATION OF RECYCLED WATER USE: (Must attach facility plan or sketch of property)
A. Estimated area of recycled water use in square feet/acreage:
10. DESCRIPTION OF RECYCLED WATER USE:
11. ESTIMATED QUANTITY OF RECYCLED WATER REQUIRED & TIME PERIOD:
12. METHOD OF TRANSPORTING AND APPLYING RECYCLED WATER:
13. NUMBER OF EMPLOYEES AND DUTIES AT WORK SITE:
14. AUTHORIZED REPRESENTATIVE (customer) STATEMENT:
I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gathered and evaluated the information submitted. Based upon my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fines and imprisonment for falsifying this information.
Name:	Title:
Signature:	Date:
15. LOCAL WATER PURVEYOR STATEMENT (BBCCSD):
Based upon the information supplied by , the Big Bear City Community Services District will allow conceptual approval of reclaimed water for the project identified above. Final approval will be contingent upon review and approval of the permit issued by the Big Bear Area Regional Wastewater Agency.
Name:	Title:
Signature:	Date:
16. BBARWA USE ONLY:
Indemnification Received by (initials):	Date:
Permit Approved and Issued:	Date:
Denied	Date:
Name:	Title:
Signature:	Date:
17. DEPT. OF HEALTH INFORMATION:
Approved:	Date:
Approved By:	Name: