HomeMy WebLinkAboutIDNR_-_State_Revolving_Fund_-_Hwy_63_-_5.17.2021 CLEAN WATER STATE REVOLVING FUND
INTENDED USE PLAN (IUP) APPLICATION
Application Packet Checklist
Application Packet Instructions
IUP Application Form SRF
Real Property Assurance Form
STATE
The application for inclusion on the Clean Water State Revolving Fund (CWSRF) IUP can be submitted REVOLVING FUND
only when the wastewater project is at the right stage of the construction permitting process. This
packet outlines the requirements of the permitting process that must be met and includes the materials and information
needed to complete the IUP application. Please use the checklist and instructions to make sure your application is
complete before submitting it.
APPLICATION PACKET CHECKLIST
A. Construction Permitting Information --To Be Completed by Applicant For DNR Use
Applicant Name City of Waterloo, Iowa
1. DNR Number(e.g. W2014-####or S2014-####) Yes ❑ No ❑
2. DNR Project Manager Name Larry Bryant, P.E. Yes ❑ No ❑
3. Project Identification: US Highway 63 South Interceptor Sanitary Sewer Upgrade- Phase I Yes ❑ No ❑
4. Project Initiation Meeting Held (date) Yes ❑ No ❑
5. Flows and Loads Concurrence by DNR (date or N/A) Yes ❑ No ❑
If N/A, state reason: N/A, Per Master Plan 2017
6. Wasteload Allocation Completed (date or N/A—see 5. above) N/A Yes ❑ No ❑
7. Antidegradation Alternatives Analysis Required (if no, go to 8.) Yes ❑ No ❑X Yes ❑ No ❑
7a. Alternatives Analysis Approved by DNR (date or N/A) N/A Yes ❑ No ❑
8.Three Copies of Certified Facility Plan Yes ❑X Yes ❑ No ❑
8a. If Already Submitted (submitted date) Certification Date: Yes ❑ No ❑
9. Iowa Construction Permit Application Schedule A Yes 0 Yes ❑ No ❑
10. Schedules F and G (if needed for the project) Yes ❑ N/A ❑X Yes ❑ No ❑
If N/A, state reason: Improvement of Collection System, No New Treatment
I I
For DNR Use: The Applicant has followed the DNR Wastewater Construction Permitting Process and the project is eligible
to be placed on the IUP pending review of the SRF information requirements.
DNR Project Manager: Date:
I I
B. State Revolving Fund Information --To Be Completed by Applicant For SRF Use
11. IUP Application Signed Yes X❑ Yes ❑ No ❑
12. DUNS Number Included (note: Form 4700-4 no longer required) Yes ❑X Yes ❑ No ❑
13. Property Assurance Form Signed Yes 0 Yes ❑ No ❑
14. SRF Environmental Review Checklist and Attachments Completed and Submitted Yes 0 Yes ❑ No ❑
For SRF Use: The IUP application materials are complete.
The application will be placed on the IUP (IUP Year), (1UP Quarter) with CWSRF Number CS1920
DNR SRF: Date:
I I
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DNR Form 542-1320
CLEAN WATER STATE REVOLVING FUND
INTENDED USE PLAN (IUP) APPLICATION INSTRUCTIONS
ITEMS 1—9: Wastewater Permitting
The Clean Water SRF Intended Use Plan Application will only be accepted when Items 1-9 have been
completed through the Wastewater Construction Permitting Process of the DNR Wastewater Engineering SRF
Section. Please refer to the Wastewater Permitting Process Manual for detailed information on these STATE
steps. REVOLVING FUND
1. DNR Number(e.g. W2014-####or S2014-####):All wastewater construction projects are assigned unique
numbers for tracking by DNR. A number beginning with W and the fiscal year indicates a Work Record. A number
beginning with S and the fiscal year indicates a Project.
2. DNR Project Manager Name:A project manager from the DNR Wastewater Engineering Section is assigned to each
project.
3. Project Identification:A brief description of the project is required in Design Schedule A, General Information. The
project description must fall under the project scope established at the project initiation meeting.An accurate
description is necessary because multiple construction contracts may have the same project numbers.
4. Project Initiation Meeting Held (date): A project initiation meeting must be held with the DNR, Owner, Consulting
engineer(licensed professional engineer), and other parties.
5. Flows and Loads Concurrence by DNR (date): If flows and loadings will change due to the project,the DNR Project
Manager must concur with the proposed design flows and loadings prior to preparing the Facility Plan.
6. Wasteload Allocation Completed (date): If a Wasteload Allocation is required for the project, it must be received
by the Owner before preparing the Facility Plan.
7. Antidegradation Alternatives Analysis Required; 7a. Alternatives Analysis Approved by DNR (date): If an
antidegradation alternatives analysis is required for the project, it must be approved by the DNR Project Manager
before the Owner prepares the Facility Plan. If a Facility Plan is submitted prior to DNR approval of
Antidegradation Alternatives Analysis, it will not be accepted for review.
8. Three Copies of Certified Facility Plan; 8a. If Already Submitted (date) and Certification Date:After completing all
applicable planning steps as discussed above,the Facility Plan may be submitted to DNR. If three copies of the
Facility Plan have already been submitted, please note the date submitted and certified and do not send additional
copies.
9. Iowa Construction Permit Application Schedule A: Design Schedule A must be certified by both the Owner and the
Consulting engineer(licensed professional engineer). It is required for all wastewater projects. Schedule A must
indicate that Clean Water SRF financing will be requested to be considered as part of this IUP application.
10. Schedules F and G (if needed for the project): Schedule G provides Wastewater Treatment Plant project design
information and Schedule F provides site information for treatment process site selection.
ITEMS 11-14: Clean Water SRF
11. IUP Application Signed:The Intended Use Plan application must be signed by the Owner's authorized
representative.
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DNR Form 542-1320
12. DUNS Number Included:The Dun and Bradstreet Number(DUNS) was collected as part of EPA 4700-4 form.That
form is no longer required for SRF applicants. If the Owner does not have a DUNS number,go to
http://fedgov.dnb.com/webform to request one. While loan recipients no longer have to fill out the 4700-4 form,
it is important to note that they are still required to comply with Title VI of the Civil Rights Act of 1964.Title VI
provides that no person in the United States shall, on the grounds of race, color, or national origin, be excluded
from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity
receiving Federal financial assistance.
13. Property Assurance Form Signed:This form is required whether or not the Owner currently intends to purchase
land using SRF funds. Land for siting treatment facilities is an eligible cost as of October 1, 2014.
14. SRF Environmental Review Checklist and Attachments Completed and Submitted:The ER checklist outlines the
information needed to start the SRF ER Services.
Supporting materials may be requested to document funding requests and system needs.
Please include the following items with your application:
• Three official copies of the Facility Plan (unless previously submitted)
• Iowa Construction Permit Application Schedules A(and F and G where applicable).
• Materials included in Exhibit 5: SRF Environmental Review Checklist
• Real Property Assurance Form with authorized signature
Application materials should be sent to:srf-iup@dnr.iowa..gov
Quarterly Application Deadlines
For More Information about the Clean Water SRF IUP Application, contact Theresa Enright, 515-725-0498 or
Theresa.enright@dnr.iowa.gov.
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DNR Form 542-1320
CLEAN WATER STATE REVOLVING FUND
INTENDED USE PLAN (IUP) APPLICATION FORM
This form may be used to apply for inclusion on the project priority list of the Clean Water SRF IUP at the time a
complete Facility Plan is submitted. IUPs are developed on an annual basis with quarterly updates as needed.This form
is not an application for a loan. SRF loan application materials may be obtained at www.lowaSRF.com.The loan
application should not be completed until after bids are received.
Instructions:
Complete the requested information in the following sections to the best of your ability. Please print or type the
information on the form. If a particular item does not apply to your system, enter n/a for"not applicable." Attach
supporting documentation as needed. Keep a copy of the completed application for your records, submit a copy to your
engineer, and submit the signed form to the following e-mail address: srf-iup@dnr.iowa.gov
For more information about the Clean Water SRF IUP Application, contact Theresa Enright at 515-725-0498 or
Theresa.Enright@dnr.iowa.gov
Section 1:Applicant and Consulting Engineer Information
Applicant Name: City of Waterloo, Iowa
Applicant Address: 715 Mulberry Street
City: Waterloo State: IA Zip: 50703
Authorized Representative: Mayor of Waterloo,Quentin Hart
Telephone Number: 319-291-4301 E-mail: mayor@waterloo-ia.org
Signature: Q +" H`r - Title: Mayor
*DUNS Number: 058005404
Consulting Engineer: Ross Hillsman, P.E.
Firm: (specify branch where consulting engineer is located) AECOM
Firm Address: 501 Sycamore Street,Suite 222
City: Waterloo State: IA Zip: 50703
Telephone Number: 319-232-6531 E-mail: Ross.Hillsman@aecom.com
NPDES Facility No.: 0790001
Section 2: Project Schedule
Anticipated final plans and specifications submittal date: July 15,2021
Anticipated construction start date: September 15, 2021
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DNR Form 542-1320
Section 3: Brief Project Summary(Attach additional pages if necessary.)
Describe the reasons for the proposed project: (i.e. specific water quality problem or system improvement)
US Highway 63 portion of the Waterloo, Iowa sanitary sewer collection has been identified as an area that requires attention due to
high wet weather flow rates, backups,and the condition of the sanitary sewer system infrastructure in the area. The primary
objective of the US Highway 63 South Interceptor Sanitary Sewer Upgrade-Phase I and Home Park Boulevard neighborhood Sanitary
Sewer Improvements project:To eliminate sanitary sewer and manhole surcharging in the area and improve the condition of the
infrastructure.
Describe the proposed project: (i.e., specific solution to the water quality problem, or proposed system improvement)
Upgrade and increase the capacity of the sanitary sewer along US Highway 63 and provide a relief sewer from the Home Park
Boulevard neighborhood to help mitigate backups during periods of high flow. The sanitary sewer upgrades along US Highway 63 are
planned to be completed in three phases. Phase I is approximately 6400 LF along US Highway 63 and approximately 1500 LF for relief
sewer to the Home Park Boulevard neighborhood.
Which other funding programs are you considering to assist in completion of this project? (Check all that apply)
❑ Community Development Block Grant (CDBG)
❑ Rural Development Grant and/or Loan
❑ Reserve Funds
❑ Other:
Compliance Status
❑ Has been referred to the Iowa Attorney General
❑ Has received administrative order from DNR
❑ Under compliance schedule in the NPDES permit
❑X Other: City is under a Consent Decree by the US EPA and the Iowa DNR
Section 4: Project Environmental Outcomes
Primary Impacted Waterbody NHD Reach Code: Cedar River&Black Hawk Creek
Designated Surface Water Uses (e.g.Al, BWW): Al,Class B(WW1),Class HH
Project Will Contribute to Water Quality... (check one)
❑ Improvement
❑X Maintenance
❑ Not Applicable
Project Will Allow the System to... (check one)
❑Achieve Compliance
❑X Maintain Compliance
❑ Not Applicable
Project Will Allow the System to Address... (check all that apply)
❑X Existing TMDL
❑ Projected TMDL
❑ Watershed Management Plan
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DNR Form 542-1320
Section 5: Project Cost
Cost Category Estimated Total Cost in
Legal Expenses 10,000
Land and Easements +10,000
Engineering Planning Fees +
Engineering Design Fees +360,000
Engineering Construction Fees +391,000
Construction +3,753,000
Equipment +
Other: +
Other: +
PROJECT SUBTOTAL =4,524,000
Contingencies +751,000
Planning and design loan proceeds, if rolling
into construction loan +
Less Any Funds Requested from Other Sources -
LOAN SUBTOTAL =5,275,000
Loan Initiation Fee (Loan Subtotal x.005) +26,375
TOTAL IUP REQUEST(Round to the nearest$1,000) =5,301,000
Section 6:Consultants
Bond Counsel Firm: Ahlers Cooney
Contact Person: Kristin Billingsley Cooper
Mailing Address: 100 Court Avenue,Suite 600
City: Des Moines State: Iowa Zip: 50309-2231
Telephone Number: 515-246-0330 E-mail: kcooper@ahlerslaw.com
Municipal Advisor Firm: Speer Financial, Inc.
Contact Person: Maggie J. Burger
Mailing Address: 531 Commercial Street,Suite 608
City: Waterloo State: Iowa Zip: 50701
Telephone Number. 319-291-2077E-mail: mburger@speerfinancial.com
*Please provide these contacts if known at the time of application.The requirement to engage a Municipal(Financial)Advisor is new to SRF for
projects starting in fiscal year 2015.
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DNR Form 542-1320
Section 7:Acquisition of Property by SRF Applicants
US ENVIRONMENTAL PROTECTION AGENCY
ASSURANCE WITH RESPECT TO REAL PROPERTY ACQUISITION
OF TITLE III OF THE UNIFORM RELOCATION ASSISTANCE AND REAL PROPERTY
ACQUISITION POLICIES ACT OF 1970 AS AMENDED
City of Waterloo
The (Applicant) hereby assures that it has authority under applicable State and
local law to comply with Section 213 of the Uniform Relocation Assistance and Real Property Acquisition Policies Act of
1970, Public Law 91-646, 84 Stat. 1894 (42 U.S.C.4601) as amended by the Surface Transportation and Uniform
Relocation Assistance Act of 1987,Title IV of Public Law 100-17, 101 Stat. 246-256 (42 U.S.C. 4601 note) and 49 CFR
1.48(cc); and certifies, assures and agrees that, notwithstanding any other provision set forth in the application.
1. For projects resulting in the displacement of any person:
a. It will adequately inform the public of the relocation payments and services which will be available as set forth in
Subparts A, C, D and E of 49 CFR 24.
b. It will provide fair and reasonable relocation payments to displaced persons as required by Subparts D and E of
49 CFR 24.
c. It will provide a relocation assistance program for displaced persons offering services described in Subpart C of
49 CFR 24.
d. Comparable replacement dwellings will be available pursuant to Subpart F of 49 CFR 24, or provided if
necessary, a reasonable period in advance of the time any person is displaced.
e. In acquiring real property, it will provide at least 90 days written notice to each lawful occupant of real property
acquired, stating the date such occupant is required to move from a dwelling or to move his business or farm
operation.
2. For projects resulting in the acquisition of real property:
a. It will fully comply with the requirements of Subpart B of 49 CFR 24.
b. It will adequately inform the public of the acquisition policies, requirements and payments which apply to the
project.
c. It will make every effort to acquire real property expeditiously through negotiation.
d. Before the initiation of negotiations it will have the real property appraised and give the owner or his
representative an opportunity to accompany the appraiser during inspection of the property, except as provided
in 49 CFR 24.102(c)(2).
e. Before the initiation of negotiations it will establish an amount which it believes to be just compensation for the
real property, and make a prompt offer to acquire the property for that amount; and at the same time it will
provide the owner a written statement of the basis for such amount in accordance with 49 CFR 24.102.
f. Before requiring any owner to surrender possession of real property it will pay the agreed purchase price; or
deposit with the court,for the benefit of the owner, an amount not less than the approved appraisal of the fair
market value of the property; or pay the amount of the award of compensation in a condemnation proceeding
for the property.
g. If interest in real property is to be acquired by exercise of the power of eminent domain, it will institute formal
condemnation proceedings and not intentionally make it necessary for an owner to institute legal proceedings
to prove the fact of the taking of this real property; and
h. It will offer to acquire the entire property, if acquisition of only part of a property would leave its owner with an
uneconomic remnant.
References to 49 CFR are citations to Title 49, Code of Federal Regulations, Part 24, published in the Federal Register Vol.
54, No.40, March 2, 1989.
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DNR Form 542-1320
This document is hereby made part of and incorporated in any contract or agreement, or any supplements and
amendments thereto, relating to the above-identified application and shall be deemed to supersede any provision
therein to the extent that such provisions conflict with the assurances or agreements provided therein.
City of Waterloo
(Legal Name of Applicant)
By (�.4414 H� F
(Signature of Authorized Representative)
5/17/2021
(Date)
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DNR Form 542-1320
SRF Environmental Review Checklist
The following checklist outlines the information needed to start the SRF Environmental Review (ER)
Services. Please provide the following to: srf-iup@dnr.iowa.gov
*Environmental Review Services will not be initiated until after all items marked REQUIRED are received. SRF
Applicant Name: City of Waterloo STATE
REVOLVING FUND
✓ Other federal funding sources that will be used for the proposed project. (Check ALL that apply)
❑X No other federal funding sources are planned.
❑ CDBG
• What amount was requested? $
• Has the funding amount been awarded? ❑Yes ❑ No
• Who is preparing the environmental review documents for this funding source? Please provide contact
information.
❑ USDA-RD
• What amount was requested? $
• Has the funding amount been awarded? ❑Yes ❑ No
• Who is preparing the environmental review documents for this funding source? Please provide contact
information.
❑ Other: Please specify program
• What amount was requested? $
• Has the funding amount been awarded? ❑Yes ❑ No
• Who is preparing the environmental review documents for this funding source? Please provide contact
information.
✓ The anticipated construction start date for the proposed project. (Check ALL that apply)
❑X The anticipated construction start date on the current IUP application is correct.
❑The anticipated construction start date has changed from the date listed in the IUP application.
• What is the new anticipated construction start date for the project?
❑The proposed project schedule is dependent on other funding source(s).
• Will the construction start date be delayed if other funding is not awarded? ❑Yes ❑ No
❑The proposed project schedule is dependent on an existing compliance schedule.
• What is the construction start date listed in the compliance schedule? 15 September 2021
✓ A description of the current project scope including: what is proposed to be constructed, specific construction
methods that will be used, estimated dimensions (length,width, depth) of excavated areas and the proposed
construction schedule if construction will be phased (REQUIRED).
To upgrade and increase the capacity of the sanitary sewer along US Highway 63 and provide a relief sewer within the Home Park
Boulevard neighborhood to help mitigate backups during periods of high flow. The sanitary sewer upgrades along US Highway 63
are planned to be completed in three phases. Phase I is approximately 6400 LF and Home Park Blvd is approximately 1500 LF.
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Page 1 of 3 DNR Form 542-0618
✓ Indicate if any of the following ancillary impacts will result from the proposed project. (Check ALL that apply)
❑Abandonment or demolition (partial or entire) of existing building/structures
❑ Borrow pits
❑X Staging areas for equipment and materials
❑X Temporary and/or permanent easement areas
❑X Pavement replacement(street, driveway, sidewalk)
❑ New access for roads/utility lines
✓ A recent aerial map with the marked boundaries of the project area.The map should also include labeled location(s)
of all proposed construction boundaries (include any ancillary impacts listed above as applicable). If a specific area
has yet to be defined, please mark a larger area that will include the final project area.
❑X An aerial map of the project area map is included (REQUIRED):
• What is the approximate size of the total project area? 25.9 acres
• How much of the total project area will be impacted by ground-disturbing (excavation,grading,tree removal,
etc.) construction activity? 25.9 acres
❑X A site sketch of the project area map is included with the following(REQUIRED):
• All locations of ground disturbance and staging areas marked
• North arrow
• A minimum of one labeled street
❑ Shape files have been provided
✓ Photos with a descriptive caption (include location & direction) of the project area showing current land use and
habitat.
❑X Photos with captions are included (digital files are preferred).
✓ Indicate which of the following impacts are anticipated as a result of the proposed project. (Check ALL that apply)
❑ Demolition, abandonment or rehabilitation of any building/structure over 50 years old. Picture(s) showing the
interior and exterior fagade of the building/structure should be provided. Provide the following information for each
building/structure over 50 years old that will be impacted.
• What year was the building/structure originally constructed? If the exact year is unknown, provide an 13
estimate(REQUIRED).
• What material(s) is the building/structure made of?
• Have any additions or substantial alterations to the building/structure occurred? If so, describe what was done
and when.
❑ Brick sewers or street surfaces will be disturbed by construction activity.
• Has a historic context(including Iowa Site Inventory Forms) been prepared for the brick sewers/street
surfaces? ❑Yes ❑ No
• Describe any planned steps to minimize adverse effect to the brick sewers/streets.
❑ Existing prairie will be disturbed by construction activity.
• How much prairie will be disturbed? acres
• Has a floral study been conducted of the prairie area? ❑ Yes ❑ No
• Describe any planned steps to minimize adverse effect to the prairie.
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Page 2 of 3 DNR Form 542-0618
❑Trees (greater than 4" diameter breast height)will be removed.
• Will tree removal occur between October 1 and March 31 to avoid impacting federally threatened or
endangered bat species during the summer maternity period? ❑ Yes ❑ No
❑Wetlands will be disturbed by construction activity.
• How much of the wetland area will be permanently impacted? acres
• Has a Joint Application been submitted to determine permit requirements? ❑ Yes ❑ No
**In the interest of keeping your project on schedule, SRF recommends submitting the Joint Application prior to or immediately
following the submission of this document.
❑ Planned stream/creek crossings.
• What is the name of the stream/creek crossing?
• What construction method(s) are planned for the crossing?
• Will excavation activity take place to the bed, bank of the stream/creek? ❑ Yes ❑ No
• Has a Joint Application been submitted to determine permit requirements? ❑ Yes ❑ No
❑X Planned work within a mapped 100-year flood plain.
• What construction activity is planned within the flood plain? Installation of Sewer, Replace to Existing Grade
• If ground disturbance will occur, will pre-construction contours be restored after construction activity is
completed? ® Yes ❑ No
• Has a Joint Application been submitted to determine permit requirements? ❑ Yes ® No
❑ Planned work within state or federal owned and/or managed land.
• What construction activity is planned within state/federal land?
• Has a Joint Application been submitted to determine permit requirements? ❑ Yes ❑ No
❑ Farmland will be permanently converted to non-agricultural uses.
• What is the total size of the farm unit(s)that contains the project area? acres
• How much of the project area has been farmed (managed for a scheduled harvest or timber activity) more
than 5 of the last 10 years? acres
• How much of the project area will be permanently converted from agricultural use as a result of the proposed
project? acres
✓ Landowner permission is required for archaeological survey on private property, if needed. *Please note that
archaeological survey will not begin until this permission is obtained.
❑Yes, landowner permission has been obtained (documentation is provided).
• Does the landowner(s) have any specific requests or requirements for archeological work to be conducted
(for example, before/after harvest)? acres
❑ No, landowner permission has not been obtained at this time.
• When is landowner permission anticipated to be obtained?
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Page 3 of 3 DNR Form 542-0618
HuntiZton Rd.
Lulu St. 0
Peoria St.
/Legend >
Robin Rd. CONNECT AND OUTLET TO Summit Ave.
'6 EXISTING SANITARY SEWER .0 Summit Ave.
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HOME PARK BLVD 18" 2E
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EXHIBIT 5
AERIAL AND SITE PLAN
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SANITARY SEWER UPGRADE PHASE I
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D 0 Q n"" CITY OF WATERLOO,IOWA
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4 Orange Grove Road(Alley)between Home Park Blvd and
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5 W 3rd and US Hwy 63 Intersection,Facing North 6 W 3rd and US Hwy 63 Intersection,Facing South
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7 US Hwy 63 Facing South, Directly West of Home Park 8 US Hwy 63,Facing South, Coming upon Ansborough
Blvd Intersection
4
9 Ansborough Ave& US Hwy 63 Intersection,Facing Southwest
10 US Hwy 63 Facing South,Directly West of Carrington
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11 Ansborough Ave South of US Hwy 63 Intersection,Facing West
12 US Hwy 63 Facing South,Near Upland Drive
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13 US Hwy 63 Facing South,Directly West of 14 US Hwy 63 Facing South,North of Martin Road
Meadowbrook Lane
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16 US Hwy 63 Facing South,Directly West of Jane Street
15 US Hwy 63 Facing South,Directly West of Celebration
Church
Iowa Department of Natural Resources
Wastewater Section
❑ Construction Permit Application
SCHEDULE A, Construction Permit Application
Exhibit 11A
APPLICANT ENGINEER
Owner: City of Waterloo Firm: AECOM
Address: 3505 Easton Avenue,Waterloo, Iowa 50702 Address: 501 Sycamore Street,Waterloo, Iowa 50703
Representative: Randy Bennett Project Officer: Ross Hillsman, P.E.
Phone Number: 319-291-4553 Phone Number: 319-232-6531
Email: randy.bennett@waterloo-ia.org Email: Ross.Hillsman@aecom.com
Project Identification: US Highway 63 South Interceptor Sanitary Sewer Upgrade-Phase I
IEstimated Start Date*: 09-15-2021 Estimated Completion Date: June 2023 I
PLEASE RESPOND TO ALL QUESTIONS Yes No
1. Has an engineering report,facilities plan or other information previously been submitted for this project? Q ❑
If Yes: Project Identity: Waterloo-Master Plan Date Submitted: December,2017
2. Does the project and construction permit application,as submitted,follow the recommendations, design loadings, ❑ ❑
construction schedule, permit limits, and conclusions of the approved engineering report or facilities plan?
If No: Provide the design basis and technical information justifying all changes.
3.Are there three complete sets of plans and specifications accompanying this application? ❑X ❑
For a minor gravity sewer extension within the meaning of 455B.183.3 Code of Iowa and Design Standard 11.1,two complete
sets will be adequate for expeditious approval. For more complex projects,three sets of plans and specifications may be
requested.
4.Are approved standard specifications a part of this application? ❑ ❑
If Yes: Approved Standard Specifications of
(municipality or firm): Iowa SUDAS-2021 Edition Date Approved:
5. Does each set of plans and specifications or engineering report accompanying this application contain a a ❑
"professional engineering seal"executed in conformance with 54213.16, Code of Iowa?
If No: Processing will be delayed pending receipt of applicable design schedules and certified plans,specifications or
engineering report.
6. Is this a joint wastewater and water supply project? ❑ Q
If Yes: A construction permit application for the water supply project should be submitted separately to the Water Supply
Section.A Water Supply permit fee may be required.
7. Is the applicant to provide treatment of effluent resulting from this construction? ❑X ❑
If No: A Sewage Treatment Agreement executed by the authority providing treatment must accompany this form.
8. Is a new or amended operation permit necessary to use the facilities described in this application? ❑ Q
If Yes: A new or amended permit to operate may be requested prior to the receipt of a construction permit.
9. Is any waterline located within 10 feet; or any private or public well, lake, or public recreation area located within ❑
400 feet of the proposed construction?
If Yes: Identify and locate the facility(ies) relative to the proposed construction.
10.Will construction inspection be conducted by a licensed engineer employed by the applicant? M ❑
If No: Name of Engineering Firm Conducting Inspection: AECOM
11.Will this project utilize CWSRF loan funds? Q ❑
CERTIFICATION
APPLICANT ENGINEER
I certify that I am the authorized representative of the owner I certify that all aspects of the design included in this application
and state that the project identified above is approved by the conform to applicable standards contained in Chapter 567 IAC
owner. 64,or that an explanation and justification for any proposed
variations from such standards is attached. I am familiar with the
information contained in this application and,to the best of my
knowledge,such information is complete and accurate.
Signature Date Signature Date
*Estimated Construction Start Date:Complete applications must be submitted at least 120 days in advance of the date for starting
construction in accordance with Rules 567 IAC 60.4 and 64.2
Please complete the Schedule Checklist on the following page of this form.
04/2016 cmc DNR Form 542-3129;28A
DOCUMENT CHECKLIST
Identify all categories included in this project.Also, identify schedules attached to this application.
Schedule Title Attached Included in Project Submittal Date
B Collection System ❑ ❑X
IC Lateral Sewer Extension ❑ ❑
ID Trunk&Interceptor Sewer ❑ ❑
E Wastewater Pump Station ❑ ❑
F Treatment Project Site Selection ❑ ❑
IG Treatment Project Design Data ❑ ❑
IH1 Schematic Flow Diagram ❑ ❑
H2 Treatment Process Loading and Removal Efficiency ® ❑
H3 Mechanical Plant Reliability ❑ ❑
I Screening, Grit Removal and Flow Measurement ❑ ❑
J Septic Tank System ❑ ❑
K1 Controlled Discharge Pond ❑ ❑
IK2 Aerated Pond ❑ ❑
IK3 Anaerobic Lagoon ❑ ❑
L Setting Tanks ❑ ❑
M Fixed Film Reactor-Stationary Media ❑ ❑
N Rotating Biological Contactor ❑ ❑
IO Aeration Tanks or Basins ❑ ❑
P Gas Chlorination ❑ ❑
Q Sludge Digestion and Holding ❑ ❑
IR1 Sludge Dewatering and Disposal ❑ ❑
R2(A&B) Low Rate Land Application of Sludge ❑ ❑
R3 Land Application of Sewage Sludge(To be developed) ❑ ❑
IS Land Application of Wastewater(To be developed) ❑ ❑
ISewage Treatment Agreement ❑ ❑
Identify any categories included in this project which are not provided in the above list of schedules.
11/2015 cmc DNR Form 542-3129;28A
IOWA DEPARTMENT OF NATURAL RESOURCES CASHIER'S USE ONLY
�Lk
Wastewater Disposal System Construction Permit 0945-542-NPDE-CP-057032-3202
Application Fee Form Owner
Owner Name: City of Waterloo, Iowa
Address: 3505 Easton Avenue
City, State, Zip: Waterloo, Iowa 50702
Project Identification: US Highway 63 South Interceptor Sanitary Sewer Upgrade - Phase I
® $100 Fee enclosed
Please sign and return this form with a check or money order payable to "Iowa Department of Natural Resources".
Place it and the check or money order on top of other Construction Permit Application documents.
Effective beginning July 1, 2006, Applications for Construction Permits for wastewater disposal systems required by
Iowa Code 4556.173 and rules in Iowa Administrative Code 567 IAC 64, must be accompanied by the fee required by
Iowa Code 4556.197 and Iowa Administrative Code 567 IAC 64.16(3)"c".
The fee is $100 for each application, regardless of project size and project type including sanitary sewers, pump
stations, treatment units or a combination thereof. The fee shall be submitted with the certified engineering documents
necessary to apply for a construction permit (plans, specifications and related application schedules A, F, and G as well
as the appropriate schedules indentified on page 2 of Schedule A). The construction permitting process is initiated as
planning for construction begins. Planning coordination and submittal of preliminary engineering reports or facility plans
precedes submittal of technical documents necessary to constitute a construction permit application. The application
fee is not necessary when submitting a planning document but must accompany construction permit application
documents. A fee should accompany each permit application received on or after July 1,2006.
Failure to submit a fee with the application may delay the processing of a construction permit. If you have any questions
regarding the application fee, please contact Donna Gomm at 515-725-8427 or Donna.Gomm@dnr.iowa.gov
Signature of Owner or Representative:
Printed Name: Quentin Hart, Mayor
Telephone or email contact:
Mail to:
Iowa Department of Natural Resources
Wastewater Engineering Section
502 East 91"Street
Des Moines, IA 50319-0034
11/2014 cmc DNR Form 542-1245