HomeMy WebLinkAboutIDNR - Gardner Addition 9.14.20 Iowa Department of!Natural Resources
D Wastewater Section
Construction Permit Application
Sewage Treatment Agreement
INSTRUCTIONS
This agreement must be executed for all projects where construction and sewage treatment will be provided by different parties;
i.e.,a private subdivision connecting to a municipal system.This agreement must be executed by the parties who are owners at the
time the permit is issued,regardless of whether title to the proposed construction project will be transferred after completion of the
project.
This agreement is not necessary when a contract for sewage treatment already exists;i.e.,service contracts between municipalities.
However,the Department of Natural Resources must be informed in writing that the contractual agreement does exist.
APPLICANT ENGINEER
Owner: GBS Development LLC Firm; Clapsaddle-Garber&Associates
Address: 1732 Pinehurst Lane Address; 16 E.Main Street
Representative: Phillip Shirk Project Officer: Adam C. Daters
Phone Number: 319-239-4446 Phone Number, 641-752-6701
Project Identification: Gardner Addition
Owner and System Receiving Wastes: WATERLOO CITY OF STOP-0790001
CERTIFICATION
I am the authorized representative of the owner identified above and state that the proposed sanitary sewage facilities shall be
constructed in accordance with the plans and specifications and all wastes contributed by this project shall be discharged to the
treatment s ntifl bone.
Signature Title: � s✓ Date zG2�
AGREEMENT TO PROVIDE SEWAGE TREATMENT
I am the authorized representative of the owner of the system identified above and state that the connection of the proposed
sanitary sewage facilities identified above is approved by the owner,and that the owner accepts responsibility for providing
adequate treatment of all wastes contributed by this project,in accordance with the provisions of Chapter 455B,Code of Iowa,and
the rules of the Department of Natural Resources.This agreement shall not be construed in any way to affect any local ordinances,
sewer service agreements,or fee systems entered into between the parties
Name: Quentin Hart Title: Mayor
Signature Quent(n Hart Date: 9/14/2020 Phone:
912018 cmc DNR Form 542-3219;29