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Department of Environmental Protection – Drinking Water Program
Sample Water Supply Protection Checklist
-For Coordinating Local Project Reviews -
Protecting drinking water supplies is an ongoing task for municipal officials. Once a community establishes water supply protection measures such as bylaws, health regulations and
protection plans, proposed land uses and activities must be evaluated in conjunction with the established protection.
Reviewing proposed projects, however, can be challenging. Proposed developments and projects often require permitting/reviewing officials to obtain information from other local boards
and entities. For instance, a building inspector reviewing an permit application for an industrial facility expansion that stores hazardous materials, must know at a minimum:
is the project located in a water supply area?;
is the water supply area protected by local controls?;
what condition or performance standards must the project meet to ensure protection?;
does the project have secondary/accessory uses that pose a threat to water supplies?;
what other local controls are applicable to the project?;
which local officials and entities need to be informed of this project (fire department, public water supplier, board of health, board of selectmen, etc.)?
The attached Sample Water Supply Protection Checklist was developed to provide local officials with a method for reviewing and commenting on projects prior to permitting them in water
supply areas. By coordinating information and efforts among the multiple entities that play a role in water supply protection, local officials can:
ensure that potential sources of contamination are not inadvertently permitted in water supply protected areas;
identify and mitigate potential threats posed by existing land uses;
identify and strengthen inadequate protection controls; and
enhance the protection of inter-municipal water supplies and recharge areas.
The water supply checklist can be initiated and circulated by any individual responsible for reviewing or permitting projects. The attached Sample should be modified to identify the
initiating authority, such as ‘Building Inspector Water Supply Protection Checklist’. Modifications should also be made to reflect the community’s water supply sources, local boards
and entities, and local water supply protection measures. See the Notes attached to the Sample Checklist for additional information.
Town/Authority:
THIS INFORMATION IS NECESSARY TO PROTECT DRINKING WATER SUPPLIES
I. Property Owner/Developer
Name (((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((
Mailing Address(((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((
Telephone(((((((((((((((((((((((((((((((((((((((((((((((
II. Location of Proposed Project
Site Address (((((((((((((((((((((((((((((((((((((((Assessors map-lot/parcel#((((((((((
Current zoning((((((((((((((((((((((((((((((
Proposed project is located in an Aquifer or Watershed Protection Zoning District (y/n) (((((
Proposed project is located in a DEP designated water supply zone (y/n)((((((,
Groundwater Source(s):((((((((((((((((((((((((((((
Zone I ((((((( Zone II ((((((( IWPA(((((((
Surface Water Source: ((((((((((((((((((((((((((((
Zone A((((((( Zone B((((((( Zone C(((((((
III. Description of the Proposed Project
The Type of proposed use or activity is considered: (check all that apply)
((((new development or structure (((( a change in use
((((expansion of an existing use (((( a secondary or accessory use
((((replacement of an existing structure (((( a non-conforming use
((((other ((((((((((((((((((((((((((((
Describe the proposed project:
3. The proposed project includes the following uses or activities in the Zone II, IWPA or Zone A of a drinking water source:
storage of:
((((( liquid petroleum products
((((( liquid hazardous materials
((((( deicing chemicals
((((( animal manure
((((( commercial fertilizers
((((( b) generation, treatment, storage, or disposal of hazardous waste
((((( c) non-sanitary wastewater treatment or disposal works
((((( d) stockpiling of snow/ice containing deicing chemicals
((((( e) construction of impervious surfaces
(((( f) junkyards, automobile graveyards, salvage yards
((((( g) excavation of earth material
In Groundwater Zones IIs or IWPAs
((((h) storage of sludge or septage
((((i) installation of floor drains
((((j) landfills, dumps, monofills
((((k) petroleum, fuel or heating oil bulk stations or terminals
In Surface Water Zones A
((((l) solid waste facilities
((((m) motor vehicle repair operations
((((n) cemeteries
((((o) animal standing, stabling or grazing
((((p) commercial car washes and outdoor washing of commercial vehicles
4. These activities or uses are controlled through:
Zoning Bylaws/Ordinances
Board of Health Regulations ((((((((((((((((((((((((((((((( ((((((((((((((((((((((((((((
General Bylaws/Ordinances ((((((((((((((((((((((((((((((( ((((((((((((((((((((((((((((
Not Controlled ((((((((((((((((((((((((((((((( ((((((((((((((((((((((((((((
5. The proposed project is consistent with the local regulatory control (y/n) (((((((((((
(comment)((((((((((((((((((((((((((((( ((((((((((((((((((((((((((((((((((((( ((((((((((
6. Sensitive features on the project site include:
(((((erodible soils/steep slopes ((((wetlands ((((flood plains
(((((shallow depth to groundwater ((((highly permeable soils ((((rivers/streams
(((( private (homeowner) wells ((((shallow fractured bedrock ((((other(((((((((
7. The project site/facility has existing threats (or violations) to drinking water supplies:
((((improperly abandoned well ((((unsealed floor drains
((((leaking under/above ground storage tanks ((((hazardous waste disposal/storage
((((improper hazardous materials storage ((((stormwater/flooding
((((other((((((((((((((((((((((((((((((((((((((((((
IV. Attachments
site plan/design(((((((((( map(((((((((((( other(((((((((((((((((((((
V. Comments/Additional Information
(((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((
(((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((
(((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((
(((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((
(((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((
(((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((
This information has been received/reviewed by:
Date Approval Comments Required (y/n) Attached (y/n)
((((Building Inspector ((((((( ((((((( (((((((
((((Zoning Officer ((((((( ((((((( (((((((
((((Planning Board ((((((( ((((((( (((((((
((((Board of Health ((((((( ((((((( (((((((
((((Public Water Supplier ((((((( ((((((( (((((((
((((Protection Committee ((((((( ((((((( (((((((
((((Zoning Board of Appeals ((((((( ((((((( (((((((
((((Conservation Commission ((((((( ((((((( (((((((
((((Fire Chief/Department ((((((( ((((((( (((((((
((((Adjacent Municipality
(Town/City ((((((((((() ((((((( ((((((( (((((((
Please return to the ((((((((((((((((((((((((((((((((((((((((((((((( by(((((((