DDW-2025-001268

CC:
Water/Sewer Separation - Exception Request Form
INSTRUCTIONS
Send the completed Exception Request Form, drawings, and Water/Sewer Exception Request Spreadsheet to [e-mail]
PROJECT INFORMATION
Water System Number*: DDW File Number:
Water System Name*:
Project Title*:
Project Description*:
Attachments: ☐Drawings of water line and sewer line alignments☐Water/Sewer Exception Request Spreadsheet
SUBMITTED BY
Engineer of Record
Name (Print):
PE License Number: Title:
Email: Phone:
Organization:
Signature: Date:
REVIEWED BY
DDW Permitting Engineer
Name (Print):Date:
APPROVED BY
DDW Permitting Manager
Name (Print):
Signature: Date:
EQ Docs #:
Enclosures:
Administrative Contact:
Address: