The Domestic Water Supply Permit Application is the form the Sacramento County Environmental Management Department (EMD) uses to take requests for a permit to operate a domestic water supply, under Section 116525 of the California Safe Drinking Water Act. It covers new permits, amendments and changes of ownership for community, non-transient non-community, transient non-community and state small water systems. On this page you can fill out the form online on FillingPDF and download or print the completed PDF; the application itself is returned to EMD at the address printed on the form.
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What is Domestic Water Supply Permit Application – Sacramento County, CA?
The Domestic Water Supply Permit Application is the Sacramento County Environmental Management Department (EMD) form used to apply for a permit to operate a domestic water supply: a new permit, an amendment, a change of ownership or another request.
The form states that the application is made pursuant to the California Health and Safety Code, Division 104, Part 12, Chapter 4 (California Safe Drinking Water Act), Article 7, Section 116525, which relates to domestic water supply permits. Page 1 identifies the water system, its owner and the type of request, and ends with a declaration under penalty of perjury. Page 2, headed Small Water System Permit Information, describes the system: ownership type, water source, treatment, storage, distribution, emergency provisions, population served and contacts.
On the form, the New and Change of Ownership boxes carry the code (4680) and the Amendment box carries (4690). An office-use block at the bottom of page 1 holds the LPA, SR, WA and AR numbers, the permit fee and the receipt number.
EMD lists this form among its Small Public Water Systems forms, next to the Complete SSP (Sample Siting Plan), the Request for Reclassification & Certification Form and the Emergency Notification Plan Form for Small Water Systems. Those are separate documents.
Who needs to file Domestic Water Supply Permit Application – Sacramento County, CA?
The main group is the owner of a water system that needs a domestic water supply permit to operate. The form asks you to check all that apply among four system types:
- Community Water System
- Non-transient Non-Community Water System
- Transient Non-community Water System
- State Small Water System
You also use it if an existing system's permit changes. Check Amendment and describe specifically what you are requesting, or check Change of Ownership when the system changes hands. The Other box covers requests that fit neither.
The declaration is signed by someone acting under the authority and direction of the responsible legal entity whose name the application is made under. The form has one signature block, with By, Title, Address, Telephone and Date lines, and says "I (We)", so more than one person may declare. It prints no exclusions; ask EMD whether your system needs this permit.
When to file Domestic Water Supply Permit Application – Sacramento County, CA
File the application when you need a domestic water supply permit action: a new permit, an amendment to an existing water system permit, or a change of ownership. The three triggering boxes on page 1 are New, Amendment and Change of Ownership, with Other for anything else.
The form prints no filing deadline, validity period or renewal cycle and gives no processing time. For an amendment, the form tells you to describe specifically what is being requested, so have the details of the change ready before you start. For timing questions, contact EMD at the numbers printed on the form.
Documents you need
- A drawing of the distribution system: the Distribution System entry on page 2 says to include a drawing.
How to fill out Domestic Water Supply Permit Application – Sacramento County, CA
Identify the water system
Enter the Water System Name, Site Address, City, Zip, Contact Person, the contact's Phone No. and the Mailing address.
Enter the water system owner
Give the Water System Owner's Name and Phone No., the Owner's Mailing Address and the Billing Address.
Check the type of request
Check all that apply: New (4680), Amendment (4690), Change of Ownership (4680) or Other.
Check the water system type
Check all that apply: Community Water System, Non-transient Non-Community Water System, Transient Non-community Water System or State Small Water System.
Describe the water system
Use the description space on page 1 to describe your system. If this is an amendment, describe specifically what is being requested.
Complete the declaration
Enter your name after By, then Title, Address, Telephone and Date. The declaration is under penalty of perjury and must be made under the authority and direction of the responsible legal entity.
Enter ownership, source and report details
On page 2, mark Type of Ownership (Private, Public or Mutual) and Technical Report (Yes or No). Mark Water Source as Surface or Groundwater, enter how many wells, the Source Number(s) and any Auxiliary Sources.
Describe treatment and infrastructure
Mark Treatment No or Yes and describe it if Yes. Fill in Reservoir/Storage Tanks, Pumping Stations, the Distribution System (include a drawing), Emergency and backup supply provisions and whether the cross connection control survey is completed.
Enter the population served
Complete Population Served, Area served, Number of connections, the same non-residents using the system over six months of the year, the average daily number served for 60 days, Other Users and Peak monthly population served.
Add contacts and certified operator
Under Other Information, enter the Primary Contact Name, Phone Number and Email address, then the Certified Operator's Certification Type, Name and Phone Number.
Review and download the completed PDF
Check both pages and leave the For Office Use Only block blank. Download or print the completed PDF from FillingPDF and return it as described under How to submit.
How to submit Domestic Water Supply Permit Application – Sacramento County, CA
The form names one channel: return the completed application to the County of Sacramento, Environmental Management Department, 11080 White Rock Road, Suite 200, Rancho Cordova, CA 95670.
- Return address: as above, exactly as printed under "Return application to".
- Phone: the form lists Environmental Compliance at (916) 875-8550 and Environmental Health at (916) 875-8440.
- Fax: the page footer prints the department's fax number, (916) 875-8513. The form does not say whether faxed applications are accepted, so ask EMD before sending one.
The office-use block includes a Permit Fee line. The form gives no amount or payment method, so ask EMD for the current fee and how to pay it. The form is also listed on EMD's water forms page at https://emd.saccounty.gov/content/emd/us/en/forms/water-forms.html. FillingPDF lets you fill out and download the PDF; submission follows the channels above.
Common mistakes to avoid
- Checking only one box when more than one applies; the form says to check all that apply for both the type of request and the type of water system.
- Checking Amendment without describing specifically what is being requested for the existing water system permit.
- Leaving out the drawing that the Distribution System entry on page 2 says to include.
- Submitting the declaration unsigned, or without the Title, Address, Telephone and Date lines beside the By line.
- Signing for a system without acting under the authority and direction of the responsible legal entity named on the application.
- Counting only drinking water users under Population Served; the form defines human consumption to include handwashing, oral hygiene, showering, bathing, food preparation and drinking.
- Mixing up the two non-resident counts: one is the same non-residents using the system over six months of the year, the other is the average number of different people served daily for 60 days.
- Writing in the For Office Use Only block (LPA, SR, WA, AR and receipt numbers and the permit fee).
Frequently asked questions
What is the Domestic Water Supply Permit Application?
It is the Sacramento County Environmental Management Department form for applying for a domestic water supply permit to operate a water system. You use it for a new permit, an amendment, a change of ownership or another request, under Section 116525 of the California Safe Drinking Water Act.
Is this the Sacramento County business license application?
No. This form applies for a domestic water supply permit to operate a water system, handled by the Environmental Management Department. It is not a general business license application, and nothing printed on the form relates to business licensing.
Who needs to complete the domestic water supply permit application?
Owners of a community, non-transient non-community, transient non-community or state small water system who need a permit action: new, amendment or change of ownership. The form says to check all system types that apply, and a person acting for the responsible legal entity signs the declaration.
Where do I send the Sacramento County water supply permit application?
Return it to the County of Sacramento, Environmental Management Department, 11080 White Rock Road, Suite 200, Rancho Cordova, CA 95670. The form prints no other submission channel; call (916) 875-8550 or (916) 875-8440 with questions.
Can I check more than one box on the application?
Yes. The form says to check all that apply, both for the type of request (New, Amendment, Change of Ownership, Other) and for the type of water system. Describe the system in the space on page 1, and for an amendment say specifically what you are requesting.
Is there a fee for the domestic water supply permit?
The form has a Permit Fee line in its For Office Use Only block, so a fee is recorded on the application. It prints no amount and no payment method. Ask the Environmental Management Department at (916) 875-8550 or (916) 875-8440 for the current fee.
Do I have to attach a drawing?
The Distribution System entry on page 2 says to include a drawing. The form lists no other required attachment by name, although the declaration refers to accompanying attachments. Ask EMD if your system needs additional documents.
Can I fill out the domestic water supply permit application online?
You can fill out the PDF online on FillingPDF and download or print it. FillingPDF is independent of the county and does not submit the application; you return it to the Environmental Management Department yourself.
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