Water Program Forms & Documents-Sacramento County Environmental Management Department

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Forms & Documents

Water Programs

Cross Connection Control (Backflow Prevention) Forms & Documents

Certified Backflow Prevention Assembly Tester Application Form
Certified Backflow Prevention Assembly Tester List
Approved Backflow Prevention Assembly Lists
Sacramento County Cross Connection Ordinance

Small Public Water Systems Forms & Documents

Public Water System Repair Permit Form
Small Water Systems Certified Operators List
Well Water Testing Laboratories List
Other Small Water Forms

Stormwater Compliance Forms & Documents

General Industrial Stormwater Permit Notice of Intent (NOI) form
StormWater Inspection Checklists
Stormwater Program Compliance Guidelines and Brochures

Wells Program Forms & Documents

Abandoned Wells Plot Plan Forms
Wells Program Contact List
Sacramento County Well Ordinance & Enforcement Policy
Well Application and Permit Forms
Well Driller's List
Well Water Testing Laboratories List
Well Information Documents

Cross Connection Control Program

Certified Backflow Prevention Assembly Tester Application Form Updated 02/17/2012
Adobe Acrobat (.pdf)
Backflow Assembly Test Report Form Updated 06/22/2011
Adobe Acrobat (.pdf)
Cross Connection Survey Form Updated 03/01/2011
Adobe Acrobat (.pdf)

Certified Backflow Prevention Assembly Tester List Updated 05/10/2012
Cross Connection Water Supplier Contact List Updated 03/01/2011
Sacramento County Water Purveyors Map

Cross Connection Approved Backflow Prevention Assembly Lists

To request the list of approved backflow prevention assemblies pursuant to Sacramento County Code Chapter 6.30.080, please contact Cross Connection Control Program staff at (916) 875-8400. In your request, include the size and type of assembly needed for your facility.

Example: Requesting approved list of assemblies for a two-inch (2”) reduced pressure principal assembly (RP), to be installed at 12345 A Street, Sacramento, CA 00000

The list can be sent via fax or US mail (no electronic copies will be available) and will only be provided to regulated entities where the public water supplier has contracted with EMD for program administration.

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

Small Public Water Systems

Complete SSP (Sample Siting Plan) Updated 04/27/2009
Adobe Acrobat (.pdf) Microsoft Word (.doc)
Groundwater Rule Amendment to SSP (Sample Siting Plan) Updated 12/31/2009
Adobe Acrobat (.pdf)
Lead Notification Form Updated 04/27/2009
Adobe Acrobat (.pdf) Microsoft Word (.doc)
Public Water System Repair Permit Form Updated 04/27/2009
Adobe Acrobat (.pdf) Microsoft Word (.doc)
Request for Reclassification & Certification Form Updated 04/27/2009
Adobe Acrobat (.pdf) Microsoft Word (.doc)
Domestic Water Supply Permit Application Updated 10/30/2009
Adobe Acrobat (.pdf) Microsoft Word (.doc)
Emergency Notification Plan Form for Small Water Systems Updated 10/30/2009
Adobe Acrobat (.pdf) Microsoft Word (.doc)
Public Notification Tier 2 Template Updated 02/02/2007
Adobe Acrobat (.pdf) Microsoft Word (.doc)
Historical Assessment of Radionuclide Monitoring Data Form Updated 02/02/2007
Adobe Acrobat (.pdf) Microsoft Word (.doc)

Small Water Systems Certified Operator List Updated 12/01/2009
Adobe Acrobat (.pdf)
Well Water Testing Laboratories List Updated 09/11/2009
Adobe Acrobat (.pdf)