DDW-2025-001415

Temporary Exception to Rule – Approval Form
INSTRUCTIONS
Send the completed Temporary Exception to Rule - Approval Form to [e-mail]
EXCEPTION REQUEST
PWS Name: PWS No.:
Rule(s) for which exception is
requested:
Description of rule(s):
Facility or location for which
exception is requested:
Reason why rule(s) cannot be
met:
Proposed measures to
provide equivalent protection
for public health and meet the
intent of the rule:
Acknowledgements: I understand the PWS must meet all conditions required by the Division.
I understand this Temporary Exception will be granted only for the rule(s) and location(s) listed above.
I understand the PWS must obtain an exception renewal prior to the expiration date of this Temporary
Exception. To obtain an exception renewal, re-submit an exception request with confirmation that all
conditions outlined in this Temporary Exception have been fulfilled. Exceptions granted by the Division
include an expiration date to ensure that the basis and conditions for granting the exception are verified
periodically and that the drinking water quality remains protected. After receiving your request, the Division
will determine whether this exception can be re-issued. Failure to request the re-evaluation of this exception
and obtain an exception renewal by the expiration date will result in the activation of the deficiency.
I understand this Temporary Exception may be rescinded at any time if new evidence indicates that the
conditions of this exception are no longer being met or a public health risk exists due to this exception.
The PWS will maintain a copy of this Temporary Exception Approval for future reference.
If the PWS has questions concerning this Temporary Exception, the PWS will contact the DDW Permitting
Engineer at the contact information listed below.
Enclosures:
POINT OF CONTACT
The Point of Contact may be a consultant or employee of the PWS and will be contacted should DDW have questions regarding this request.
Name: Email:
Organization: Phone:
AUTHORIZED BY
Name: Position at PWS:
Signature: Date:
OFFICE USE ONLY
DDW File No.: CC:
EQ Docs #:
PWS Admin. Contact Name:
PWS Admin. Contact
Address:
REVIEWED BY
DDW Permitting Engineer
Name: Date:
Email: Phone:
Conditions or Comments:
Exception Approval Date: Exception Expiration Date:
APPROVED BY
Name:
Signature: Date: