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ILLINOIS ENVIRONMENTAL PROTECTION AGENCY <br /> DIVISION OF PUBLIC WATER SUPPLIES <br /> PERMIT SECTION <br /> 1021 NORTH GRAND AVENUE,EAST <br /> POST OFFICE BOX 19276 <br /> SPRINGFIELD,IL 62794-9276 <br /> A.PPLICATION FOR CONSTRUCTION PERMIT <br /> 1. Name of Public Water Supplies Decatur, IL#1150150 <br /> 2. Municipality or Township City of Decatur County Macon <br /> 3. Location ofProject 1800 East Lake Shore Drive Decatur, IL 62521 <br /> 4. Title of Plans ED., Lobby and Admitting Expansions <br /> Number of Construction Drawing 38 <br /> 5. Documents being submitted: <br /> 0✓ Construction Permit Application ❑ Engineers Design Summary <br /> �✓ Schedule A-Cost Estimate ❑ Schedule GI-Well Drilling Only <br /> �✓ Schedule B -Water Main Construction ❑ Schedule GII- Well Completion <br /> ❑ Specifications ❑ Permit Fee(Water Main Only) <br /> ❑ Construction Drawings <br /> 6. Scope of Project:The project consists of constructing a parking lot and a building expansion for <br /> St. Mary's Hospital in Decatur, IL. A 12 inch fire loop will be added to the west side of the new building. <br /> 7.0 ILLINOIS COMIv1ERCE COMIVIISSION CERTIFICATION(For privately owned water companies) <br /> 7.1 Has a lication been made to the Illinois Commerce Commission for a Certificate of Public Convenience and Necessity? <br /> �Yes �✓ No <br /> 8.0 New Public Water supplies: Where the developer intends to relinquish ownership of a new public water supply to the <br /> horneowners served by that public water supply,he must submit to the Agency a copy of the Protection Covenants for <br /> effecting the transfer. Those Covenants must be approved by the ICC and should accompany this application. <br /> 9.0 Infringement on Existing Public Water Supplies: <br /> 9.1 Will any part of this project be located within the boundaries of an area served by another public water <br /> supply? ❑Yes �✓ No <br /> 9.2 If yes,name of that water supply <br /> This Agency is authorized to require this information under <br /> Illinofs Compiled Statutes,1415 ILCS 5l39(1998).Disclosure of <br /> this information is required under that Section.Failure to do so <br /> may prevent.this form frOm being processed and could result in <br /> IL5320146/PWS43 REV.8/1999 PRINTEDONRECYCLEDPAPER Your applica4ion befng denied.This form has been approved by <br /> the Forms Management Center. <br /> EXHIBIT C <br />