Authorization_to_Construct_Extension_RequestPDF

Please mail or fax this form to:
Public Water Supply Section
1634 Mail Service Center
Raleigh, North Carolina 27699-1634
Fax No.: 919-715-4374
ATC Extension OR Project Termination Request

Serial No.: Water System No.:

Project Name: Water System Name:
Please complete the applicable remaining portion of this form and return to the Public Water Supply Section.
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ATC Extension Request

We request that the Authorization to Construct (ATC) for the above referenced project be extended. The
Applicant hereby certifies that the Water System Management Plan for this project remains current and accurate.
The Engineer hereby certifies that the project site conditions and applicable Rules Governing Public Water Systems
(15A NCAC 18C) have not changed since the project was originally approved and that the project will be
constructed in accordance with the previously approved engineering reports, plans and specifications.

Reason(s) for Extension:

Applicant Name (Print): Engineer Name (Print):

Applicant Signature: Engineer Signature:

Date: Date:

Project Status: Indicate below: Engineer’s Seal:

Construction Start Date:

Construction Completion Date:

Project In-Service Date:

Project On-Hold: Comments:

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Project Termination Request

This project will not be developed. Please terminate the project.

Applicant Name (Print):

Applicant Signature:

Date:

Comments: