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HomeMy WebLinkAboutIowa DNR - Sewage Treatment Agreement - 11/7/2005 Iowa Department of Natural Resources 7-05 Wastewater Section Construction Permit Application dz„e'�) '�'o 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 FIRM �6)Vofr- Cyte-Dods A(aII , L,L, (©mpa"'� ADDRESS ��to0 Ctt3sSYcxic�S t31V&. SLti�e lad ADDRESS alb �ye� w,dyE A7rtVi (, a+�vicxn , sv-7v,�— V far Io5070Z)— REPRESENTATIVE TELEPHONE PROJECT OFFICER TELEPHONE PROJECT IDENTIFICATION OWNER AND SYSTEM RECEIVING WASTES eYICcD, CERTIFICATE I am the authorized representative of the owner identified above and state that the proposed sanitary sewerage facilities shall be constructed in accordance with the plans and specifications and all wastes contributed by this project shall be discharged to the treatment system identified above. SIGNATURE TITLE �.i AGREEMENT TO PROVIDE SEWAGE TREATMENT 1 am the authorized representative of the owner of the system identified above and state that the connection of the proposed sanitary sewerage 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. SIGNATURE TYPED OR PRINTED NAME Jam— �m u{I e TITLE PHONE NUMBER DATE /'� arar �19' a9/' �1301 /1' 7-oS DNR form 29(Nov 00) 542-3219 Iowa I3epartment ot'Natural Resources Wastewater Section Construction Permit Application SCHEDULE A,Ge neral Information APPLICANT ENGINEER OWNER FIRM Co de �Yr?SSra�c�S y)9Q{/ L.�=e - �chcr�/Ly rirteri��c Cd+ ADDRESS dOCoO Cr�o�S DQl1s ��lul/ , �tr;r2 i � ADDRESs /(P 1�r©c9Kcrrc(ge L�rrrie 11feYlt� - lOLa c SD7D� 74eY100 /o0Ja- 6070 REPRESENTATIVE TELEPHONEP OJECT OFF CE TELEPHONE ' rr zec lX� 3t� -/7B� rueeache 9 3�-7 &� PROJECT IDE.NTIFICATIO ESTIMATED START DATE 71MATED COMPLETION DATE Cut S7�C Cis Y-�1 \ PLEASE RESPOND TO ALL QUESTIONS YES NO 1. Has an enginceringreport,facilities plan or other information Previousl been submitted for this ro'ect? ❑ If Yes--> PROJECT IDENTITY DATE SUBMITTED 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? ❑/1/Ff ❑ If Nom Provide the design basis and technical information justifying all changes. 3. Are there three complete sets of plans and specifications accompanying this application'? S ❑ 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 standardspecifications a part of this application? ® ❑ If Yes=> APPROVED STANDARD SPECIFICATIONS OF DATE APPROVED (municipality or fum) 5. Does each set of plans and specifications or engineering report accompanying this application contain 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 ajoint wastewater and water supply project? ❑ rA If Yes-->A construction premit 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? ❑ If No-->A Sewage Treatment Agreement(DNR Form 29)executed by the authority providing treatment must accompany this application. S. Is anew or amended operation permit necessary to use the facilities described in this application? ❑ II 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? ❑ Q If Yes-->Identify and locate the facility(s)relative to the proposed construction. 10. Will construction inspection be conducted by a licensed engineer employed by theapplicant? ®, ❑ If No.--> NAME OF ENGINEERING FIRM CONDUCTING INSPECTION CERTIFICATION APPLICANT ENGINEER I certify that I am the authorized representative of the owner and I certify that all aspects of design included in this application state that the project identified above is approved by the owner. conform to applicable standards contained in Chapter 567 IAC' 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. SIGNATiTRE DATE SIGNATURE DATE io .P/es- A_ �k�'•r— •Estimated Unstruction Start Date: Complete applications must be submitted at least 120 days in advance of the date for starting construction In accordance with Rules 567 LAC 60.4 and 64.2 PLEASE COMPLETE THE SCHEDULE CHECKLIST ON THE FOLLOWING PAGE OF THIS-FORM DNR form 29A (Nov 00) 542-3129 Iowa Department of Natural Resources Wastewater Section Construction Permit Application SCHEDULE B Collection system DNR USE BRED PROJECT IDENTITY DATE PREP PROJECT NO. C'ros�roads r�l�lI ��'/ DATE RFVISF,D PERMIT NO. osDDS SCi/'JifC�Y� �SP�PY �,l��E'Y7S/Cl/J 1. Identify proposed construction which is subject to flooding and explain what is proposed to prevent water from entering the ;y.tem. U no portion is subject In flooding,state none. Se mint Flooding;e Protection •2. Indicate hydraulic capacity of: 1) the nearest downstream main or interceptor, 21 the nearest downstream lift station. and 3) all downstream segments where flow restriction may occur. Indicate the source and accuracy of numerical data. Segment Segment Segment Location 114 Design capacity,MGD Peak Hourly Dry weather Flow MGD(actual) Peak Hourly Wet Weather Flow MGD(actual) 13. Identify treatment facility,the design loadings and present raw waste loadings. Indicate source and accuracy of numerical data. C�/Gzfc'�'/� G�)�'���' %moo/!��/:or, Col-ific�/ f'/Q•�t Facility name and number !eC zkZ- Allo C'7 dao/ ��, �o• dl)��lt�SC� Facility Loading MGD #BOD5/day Des; , 3S /, S_ Average Wet Weather(actual) Peak Hourly Wet Weather(actual) c /DD OG'o Provide projected design loading increase, which will be added to this facility as a result of this project. Desism Loading Initi 1 Design Year Residential service area Acres Acro. Population Persons Persons Flow(100 GPCD) GPD GPD HOD5(0.17#/d%cap) #/day 4/(jay Industrial service area Acres Acres Rated flow GPD 6111) BODS #/day #/day Other (f0/Y)/tiereia / o,;� Acres Acres Rated Flow SOD GPD y i2 GPD BODS o.'7 #!day 0, 7 didav Total IIODS O,7 #/day 0"7 7 #/day Total Flow '{ _ GPD X00 GPD Peak Hourly Flow GPD /� C)�'? (;PD • Include a written explanation of items 2 and 3 if the sewer system and/or treatment facility are overloaded. 542-3095 DNR form 28B('Nov 00) Iowa Department of Natural Resources Wastewater Section Construction Permit Application SCHEDULE C,Lateral Sewer Extension DATE PREPARED PROJECTIDENTITY / DNR USE I)ATF.RF.VISEL) C�YOt roads �lCcl/ /�!®i f1� PROJECT NO. bi,!V s PEIWIT NO. 1. Dodo]basis Law Dyia Yea] CD4CD( ' ) id Resential service area Acres vl Acre< Population Persons Persons Pluto(100 GPCD) GPD GPD BOD;(0.17 r%d'cap) ttiday ^'day Industrial service arca Acres Acres Rated Flow GPD CPD BOD, >-day L''dn'. Other C1ommere,a! 0.05)) Acres Acres Rated Flow e-10r) GPD GPI) BODt 0.7 #!day, o,7 luday Total BODS 0,7 4,dav 0,7 ;day Total Flow 401) GPD GPD Peak Hourly Flow —TnryL GPD 4 L)X GPD 2. Pipe Diameter 8 Inch 10 Inch 12 inch Material A&T/YI Lb-4(5,Py)=]Ip Joint ASTM &0,7r;9 76, Minimum Slope % % % Maximum Manhole Space ft. fl. ft. Total Sewer Length ft.. R ft. Maximum Cover ft. ft. ft. Minimum Cover ft. lt. ft. 3. Construction specifications(indicate ASTM No.or other standard included in the specification). A brief description is required in each pari. A. Badding class —Ar/ 6Xc4e (lb YY7/ /)OW 4V AS7/Y! 0,;L 7�. B. pipelaying. - ff)od1'1-71edb—� V46—AM- C. Compaction C'5fYa4dcj t). Manhole X}�]-/)) (_�L7Q} L. Specified maximum Infiltration;exfiltration rate a0l) GPDPMPI F. Infillratiowcxlittralitin test procedures V-Ale&[ I Lt)n r Tc�/2L/%S//)CZ GY A/Y TG'St" G :Vimment 8t grade test procedures (1) During construction: Stake fk batter board X Laser X (21 .Mier construction, Lamping X Other H. Deflection test procedures IV 4. .are detailed manhole dratvings included: Yes ❑ No Typical frame and cover assembly NPEz-)a1.7 -/[o ,are manhole covers nonvented: Ycs N No Lj Manhole diameter 'V3 in. Manhole opening diameter 62 in. Material �Oi�Gy�>Le hnimurn sower x water main separation: Horizontal �� It. �'crtical �� r. :Ue specifications included'! /l/O ------_-----__._--- G Stream,road,or railroad crossing protection /Ui4 :s rc specifications included? DNR firm 28C(Nov 00) 542-3096