Environmental Management

• ​Cross Connection Control (Backflow Prevention) Forms & Documents
• Small Public Water Systems Forms & Documents
• Commercial/Industrial Stormwater Compliance Forms & Documents
• Wells Forms & Documents
• Well Permits and Forms

Cross Connection Control (Backflow Prevention)

• Certified Backflow Prevention Assembly Tester Application Form Updated 09/17/2021
• Backflow Assembly Test Report Form  Updated 11/13/2020
• Cross Connection Survey Form Updated 11/13/2020
• Certified Backflow Prevention Assembly Tester List  Updated 03/03/2020
  
• Cross Connection Water Supplier Contact List​  Updated 01/06/2021​
  
• Sacramento County Water Purveyors Map

Cross Connection Approved Backflow Prevention Assembly Lists

The approved list of backflow prevention assemblies is available from the University of Southern California’s Foundation for Cross-Connection Control and Hydraulic Research website located at http://fccchr.usc.edu/list.html.

Please contact our office should you have any questions.

• Cross Connection Ordinance (Sacramento County Code Chapter 6.30)
  Final, Adopted April 13, 2010

EMD Forms Main Page

Small Public Water Systems

• Complete SSP (Sample Siting Plan) Updated 09/21/2021
  Adobe Acrobat   Microsoft Word
  
• Groundwater Rule Amendment to SSP (Sample Siting Plan) Updated 12/31/2009​
  
• Public Water System Repair Permit Form Updated 11/16/2020​
  Adobe Acrobat   Microsoft Word​
  
• Request for Reclassification & Certification Form Updated 09/21/2021
  Adobe Acrobat   Microsoft Word
  
• Domestic Water Supply Permit Application Updated 09/21/2021
  Adobe Acrobat  Microsoft Word
  
• Emergency Notification Plan Form for Small Water Systems Updated 09/21/2021
  Adobe Acrobat   Micro​soft Word
  
• Public Notification Tier 2 Template Updated 02/02/2007
  Adobe Acrobat   Microsoft Word
• Historical Assessment of Radionuclide Monitoring Data Form Updated 02/02/2007
  Adobe Acrobat   Microsoft Word
• Small Water Systems Certified Operator List Updated 09/21/20201
  
• Water Testing Laboratories Updated 12/09/2020
• ​ Click here to view Funding Resources​
  

EMD Forms Main Page

Commercial/Industrial Stormwater Compliance

• Stormwater Inspection and Enforcement Policy  Updated 10/29/2012
• Stormwater Inspection Checklist for Food Facilities (Restaurants)   Updated 09/13/2012
• Stormwater Inspection Checklist for Non-Food Facilities Updated 04/26/2013

EMD Forms Main Page

Wells

• Flood Protection and Response Guidance for your Private Well. (1/28/21)​
  
• EMD Well Program Contact List  Updated 9/15/2021​
  
• Well Ordinance (Sacramento County Code Chapter 6.28)
• Final, Adopted April 13, 2010
• Well Ordinance Enforcement Policy  Updated 11/18/2020
• Damaged or Missing Wells  Updated 09/24/2021
• Guidelines for Repair and Destruction of Hand-Dug Wells  Updated 09/24/2021

Well Application and Permit Forms (Updated 11/24​/2020)

• Water Supply Well/Well Repair/Pump Repair & Replacement

• Destruction Water Supply & Monitoring Wells

• Attachment for Multiple Well Destructions  (If there is more than 1 well to be destroyed, use this form for additional wells) 

• Monitoring Wells & Soil Borings
  

• Well Inactivation
  

• Cathodic Protection & Geothermal Wells
  

• Well Driller's Authorization Letter Updated 12/03/2020
  

• Property Owner's Authorization Letter​  Updated 10/14/2021
  
• Wel​l Driller's List  Updated 12/09/2020
  
• Environmental Testing Laboratories  Updated 12/09/2020
  
• Water Testing Laboratories  Updated 12/09/2020
• Compliance Bulletin: Submittal of Well Completion Reports  Updated 09/29/2021
• Compliance Bulletin: Pump Removal Repair/Replacement  Updated 10/14/2021
  
• Compliance Bulletin: Ready Mix Sand and Ceme​nt for Water Well Seals  Updated 10/14/2021​
  
• Compliance Bulletin: Exploratory Borings Updated 09/29/2021
  
• Water Well Disinfection Stages I and II  Updated 10/14/2021
  
• Permanent & Temporary Conductor Casings Guidance Document  Updated 09/24/2021
• Important Notice: Water Well Rehabilitations  Updated 11/25/2020​
  

• Water Well Standards: State of California Department of Water Resources Bulletin 74-81
• Water Well Standards: State of California Department of Water Resources Bulletin 74-90

EMD Forms Main Page


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