Water Treatment Facility Diversion Exemption Request Form - Office of Transactions and Public Land Administration

Date*

For requesting an exemption from the Green Acres diversion process for certain treatment equipment, facilities or improvements proposed to be constructed on Green Acres encumbered parkland to address an exceedance or anticipated exceedance of a maximum contaminant level established by the NJDEP under the New Jersey Safe Drinking Water Act, N.J.S.A. 58:12A-1 et seq.

Section I. Requestor's Information

Requestor's Affiliation*

If the Requestor is an employee of the Parkland Owner, specify the employee's title below*

If "Other", explain below*

Requestor's Email Address*

Requestor's Phone Number

Additional Contact Information

If additional persons are assisting with this request, please list their contact information below.

Section II. Parkland Information

Parkland Name*

Parkland Owner(s)*

County*

Municipality*

Tax Lot Designation (Block/Lot)*

List only the block(s)/lot(s) for the tax parcel(s) on which the well that is the subject of this exemption request is located. If the well is located in more than one municipality, list the block(s)/lot(s) for each municipality separately by clicking "yes" below.

Street Address

Total Acreage

Location #2

County*

Municipality*

Tax Lot Designation (Block/Lot)*

If applicable, list only the block(s)/lot(s) for the tax parcel(s) on which the well that is the subject of this exemption request is located in the second municipality.

Street Address

Additional Locations

If the parkland containing the well is located in more than two municipalities, list additional location information here.

Section III. Water System Information

Name of Water Supply Entity*

List the name of the entity that supplies drinking water to the municipality in which the parkland is located.

Public Water System Identification Number (PWSID)*

Type of Water Supply Entity*

If "other", explain below

Section IV. Well Information

Name of Well*

List the name(s) of the well for which an exemption is requested.

Well Permit Number*

List the NJDEP well permit number for the well identified above.

Date of Installation of Well*

Treatment Plant Information*

List the treatment plant name and number associated with the well identified above.

NJDEP Permits*

List any NJDEP permits issued for the well that is the subject of this exemption request, including permit numbers.

Section V. Exceedance Information

Type of Contaminant*

List all substances for which the well that is the subject of this exemption request either exceeds or is expected to exceed the maximum contaminant level established by the NJDEP pursuant to the Safe Drinking Water Act, N.J.S.A. 58:12A-1 et seq.

Safe Drinking Water Act Violation Information*

List any Safe Drinking Water Act (SDW) Violation numbers for any maximum contaminant level (MCL) violations associated with the above exceedances.

NJDEP Correspondence

Attach all correspondence from NJDEP concerning the exceedance or anticipated exceedance listed above. PDF format only.

Drop files here or

Accepted file types: pdf, Max. file size: 500 MB.

Data for Anticipated Exceedances

For a well that has not incurred a violation, attach data demonstrating that the well is expected to exceed a MCL established by the NJDEP pursuant to the Safe Drinking Water Act.

Drop files here or

Accepted file types: pdf, xls, xlsx, csv, Max. file size: 500 MB.

Section VI. Improvement Plan

Description of Improvement Plan*

Provide a brief narrative description of the treatment equipment, facilities and/or improvements proposed to be constructed to address the exceedance or anticipated exceedance listed above, including any new access roads or new underground utility lines.

Improvement Plan*

Attach a visual depiction of the plan for the treatment equipment, facilities and/or improvements for which the exemption is requested. Detailed engineering plans are preferred. The plan must depict any parkland facilities currently located in the project area for the improvement project. PDF format only.

Accepted file types: pdf, Max. file size: 500 MB.

Minimization of Environmental Impact*

Describe all measures taken in the design of the improvement plan to minimize the environmental impact of the proposed treatment equipment, facilities and/or improvements, including measures taken to minimize the footprint of the proposed project and measures taken to avoid any tree removal.

Impact on Parkland Use*

Describe all anticipated impacts of the proposed improvement project on the use of the parkland for recreation or conservation purposes, and any measures proposed to mitigate such impacts.

Impact on Public Access*

If the proposed improvement project will impact public access to the underlying parkland in any way, describe such impacts and any measures taken to ensure that there will be comparable public access to the parkland if the proposed improvement plan is implemented.

Section VII. Governing Body Authorization

Governing Body Resolution*

Attach a resolution from the governing body of the municipality in which the parkland is located authorizing the filing of this exemption request. PDF format only.

Accepted file types: pdf, Max. file size: 500 MB.

Section VIII. Additional Information

Untitled

List any additional information you wish the Department to consider in reviewing the draft lease or use agreement. If there are any deadlines associated with this request, please list them here.

Additional Information

Please attach any additional relevant documents. List any additional documents in the space below. PDF format only.

Max. file size: 500 MB.

List any additional documents attached to this request

Office of Transactions and Public Land Administration

Request for Diversion Exemption for Water Treatment Facilities (N.J.S.A. 13:8C-53a )

Section I. Requestor's Information

Section II. Parkland Information

Location #2

Section III. Water System Information

Section IV. Well Information

Section V. Exceedance Information

Section VI. Improvement Plan

Section VII. Governing Body Authorization

Section VIII. Additional Information