DDW-2025-006636

Notification of Interim Disinfection
Use this form to request approval of a temporary disinfection system (up to a singular 12 month
period) for emergency situations during the design phase of a permanent disinfection facility.
Submit this form to [e-mail] for approval prior to implementing temporary disinfection.
Public Water System Information
PWS Name:__________________________________________________________________
PWS ID Number:______________________________________________________________
Population served by PWS:______________________________________________________
Proposed Date of Permit Expiration:_______________________________________________
Was the public notified that the system is temporarily disinfecting? If so, when was the public
notice issued? ________________________________________________________________
Name of DDW staff contacted (if applicable): _________________________________________
Reason for Temporary Disinfection (Briefly Describe):

Disinfection Method and Details
Disinfectant (e.g., Sodium Hypochlorite Solution, Chlorine Gas, Other - Specify):
____________________________________________________________________________
Is the disinfectant NSF 60 certified? (Yes / No)_______________________________________
Method of Disinfectant Feed (e.g., pump type and manufacturer):________________________
Facility ID of Source(s) being disinfected:___________________________________________
Point of Application (Specific location in the treatment/distribution system):
____________________________________________________________________________
Target Residual at the Point-of-Entry (mg/L or ppm):__________________________________
Point-of-Entry Location:_________________________________________________________
Target Residual in the distribution system (mg/L, ppm)_________________________________
Description of chlorine detention time after injection up to the POE (pipe and/or tank minimum
volumes, peak flow rate, etc.):
____________________________________________________________________________
Residual monitoring instrument:__________________________________________________
Monitoring Plan for Residual Disinfectant (Frequency and Location(s)):

Summary of disinfection (e.g. Inject liquid sodium T-chlor into the supply line from the well head.
Dosage goal will be 1 ppm of chlorine at POE inside well house and peristaltic pump will be
dosed based on flow of well and desired concentration, we will have electrician wire in a plug
that will power pump when well is running)
Certification:
I certify that the information provided in this Emergency/Temporary Disinfection Plan is accurate
to the best of my knowledge. I acknowledge that The DDW reserves the right to modify or revoke
this concurrence if necessary to protect public health. I understand that DDW will provide
additional requirements, including monitoring, in a subsequent letter.
Signature of PWS Representative _________________________________________________
Printed Name and Title of PWS Representative ______________________________________
Date of Signature:_____________________________________________________________