Public Water Supply Permit Application

PUBLIC WATER SUPPLY REGULATION APPLICATION FOR PERMIT
Pawnee Nation of Oklahoma Division of Natural Resources and Safety Phone: 918.762.3655 | Fax: 918.762.6461 | Email:dnrs@pawneenation.org 301 Agency Road, P.O. Box 470, Pawnee, OK 74058
Pawnee Nation Code of Laws PNC Title XII

General Permit Individual Permit
PERMIT TYPE

Public Water Supply System Modify an Existing Public Water Supply System
TYPE OF WATER SYSTEM

Community Water System Non-Transient Non-Community Water System Non-Community Water System Minor Water System
System Owner
Address
City
State
Zip
Phone
Email
example@example.com
Certified Operator
Certification Number
Location of Existing or New System:
Latitude
Longitude (decimal degree)
Section
Range
Range
Number of Connections
Source Water

Groundwater Surface Water
Surface Water Name
Disinfectant Method
Laboratory
Water Storage Type
Water Storage Size
Please attach a site drawing that includes: property lines, location of source water, location of 100-year floodplain, and potential source of pollution within 300 feet.
File Upload

Cancel of
By signing below, I certify that I will comply with the terms and conditions of this permit and all laws and regulations of the Pawnee Nation of Oklahoma, including providing reports and submit to inspections as required.

Clear
DATE

Month Day Year
Date
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PUBLIC WATER SUPPLY REGULATION APPLICATION FOR PERMIT