Attachment 2 - Form S-1 4-2018 - Fillable.pdf

1- DEP 7071-S1 (4/2018)

FORM S-1

See the INSTRUCTIONS for more information about selected portions of this application.

Questions on completing this application? Contact the Water Infrastructure Branch at 502/564-3410 or visit our website at http://water.ky.gov for more information.

I. CONSTRUCTION PROJECT INFORMATION

Project Name:

Name of WWTP which will treat sewage from this project:

KPDES Number of the WWTP: KY WWTP County:

Name of Receiving Collection System (if different than WWTP):

KPDES Number of Receiving Collection System (if applicable): KY Project County:

Project Latitude/Longitude (DMS): Estimated Construction Cost: $

Identify the funding sources for the project:

CWSRF SPAP Other:

If the project is SRF, is the SRF Plans and Specs Checklist included?

II. APPLICANT MAILING ADDRESS

Applicant (Entity paying for construction):

Street Address:

City, State, Zip:

Phone: Fax: E-mail:

Will ownership be transferred? � Yes, future owner will be: � No

III. DESIGN CONSIDERATIONS

A. PLANS AND SPECIFICATIONS COMPLIANCE REQUIREMENTS:

Design plans and specifications shall comply with 401 KAR 5:005 and “Recommended Standards for Wastewater

Facilities” (“Ten States’ Standards”), 2014 edition. If engineering practices, other than those contained in “Ten States’

Standards”, were used in the design, indicate the source and the corresponding portion of the design. [See 401 KAR

5:005, Section 7]

Plans and specification submittals shall meet one of the following options:

Commonwealth of Kentucky

Energy and Environment Cabinet

Division of Water

CONSTRUCTION PERMIT APPLICATION

for CLEAN WATER COLLECTION SYSTEM

2- DEP 7071-S1 (4/2018)

Submit at least one paper printed set of detailed plans (no larger than 24” x 36”) and a PDF copy of the plans and specifications on a data storage device such as a USB flash drive. Both copies shall be dated with a stamp, signature of a licensed professional engineer in Kentucky which complies with the requirements of 201 KAR 18:104.

The plans digital plans shall consist of a single pdf file and be in a folder called “Engineering Plans” and the specifications manual shall be in a folder called “Specifications”.

Submit a PDF copy of the plans and specifications digitally via the electronic form on the KY One Stop Business

Portal website. The PDF copy shall be dated with stamp and signature of a licensed engineer in Kentucky which complies with the requirements of 201 KAR 18:104 Section 3. The plans shall be submitted as a single pdf file.

B. DESIGN ENGINEER, if the project will become part of a sewer system served by a regional facility. [Section 6]

P.E.’s Name: Firm:

Street Address:

City, State, Zip:

Phone: Fax: E-mail:

C. CONFORMITY TO PLANS AND SPECIFICATIONS. Provide name of person who will inspect and certify that the constructed facility conforms to the approved plans and specifications. If the sewer lines will become part of a sewer system served by a regional facility, this person must be a professional engineer (P.E.). [Section 3]

Name: Firm:

Street Address:

City, State, Zip:

Phone: Fax: E-mail:

D. DESIGN CAPACITIES. The amount of average daily flow added by the sewer line extension is gpd. The basis for the amount of additional flow is

E. OTHER INFORMATION TO BE SUBMITTED WITH APPLICATION. Place a check (����) by the items that are included in this application or an N/A if the item is not applicable to the project.

1. A copy of a USGS 7½ minute topographic map with the locations of the proposed sewer lines shown. [Section 3]

2. If modifying, replacing or abandoning an existing facility, a closure plan indicating how the new facility will be constructed without a by-pass to a stream and the procedures that will be used for abandoning the existing facility. [Section 3]

3. If the project includes a pump station, provide the pump performance curve, design calculations, and detailed wet well drawing with elevations. [Section 8]

4. If the project includes gravity sewer lines or force mains, a plan view and a profile view of each. [Section 6]

5. A model of the hydraulic analysis if the project consists of, or is connected to a network of pumps. [Section 8]

6. A brief description of the project, including what is being constructed, who will be served by this project, the flow rate, and the flow rate calculations. [Section 8]

7. A signed letter from the owner of the proposed sewer line stating that the owner will accept responsibility for

Pete Cloutier

CHECK

Pete Cloutier

CHECK

3- DEP 7071-S1 (4/2018)

the operation and maintenance of the sewer line when it is constructed. [Section 8]

8. Letters from both the owner of the sewer system and the WWTP stating that they approve the connection and accept responsibility for the additional flow. [Section 8]

9. A written statement that the portion of the sewer system used by the connection has adequate capacity to transport the current and anticipated peak flow to the WWTP and that the portion of the sewer system used by the connection is not subject to excessive infiltration or excessive inflow. [Section 8]

10. A written statement that the WWTP has adequate capacity to treat the current and anticipated flow and is not subject to excessive infiltration or excessive inflow. [Section 8]

IV. Fees

Fees. Check or money order must be made payable to “Kentucky State Treasurer” for the total amount. Fees do not apply for a municipality, sanitation district, or other publicly owned facility. [Section 5] If claiming Non-Profit status, provide proof.

Sewer Collection Project Category: Total Amount: $

VI. CERTIFICATION

I, the applicant, certify under penalty of law that this document and all attachments were prepared under my direction or supervision. The information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine or imprisonment or both for known violations. [Section 2]

Applicant’s Name and Official Title (Type or Print)

Phone Number (Include area code)

Signature

Date