Attachment 3 - Form W-1 4-2018 - Fillable.pdf

FORM W-1

Commonwealth of Kentucky Energy and Environment Cabinet

Division of Water

CONSTRUCTION PERMIT APPLICATION

for WASTEWATER TREATMENT PLANT

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:

Project City/County:

Name of WWTP:

KPDES Number of WWTP, if known (for modifications to an existing plant): KY

Estimated cost of WWTP improvements and sewer line extension: $

Project is: � WWTP Only � WWTP with sewer lines

� Minor Modification to WWTP (Complete only Sections I, II, IV A, B, C, E3, H1, VII, VIII)

II. APPLICANT INFORMATION

Applicant (Entity paying for construction): E-mail:

Street Address:

City, State, Zip:

Will ownership be transferred? � Yes. Name of new owner: � No

III. PRELIMINARY SUBMITTAL

Has a Preliminary Submittal been made with all the information in this section? [See 401 KAR 5:005, Section 3]

� Yes. Name of project:

County and Location of project, then skip to next section:

� No. Provide the information below that has not been previously submitted (use additional pages, as necessary). Place a check

(����) by the items included in the application or an N/A if the item is not applicable to the project.

A. A copy of a 7½ minute USGS topographic map, with the WWTP, any proposed sewer lines, service area, and discharge location identified.

B. For a WWTP located within a planning area, a letter from the regional or facility planning agency stating the proposed WWTP is compatible with the regional facility plan or the water quality management plan.

C. For a WWTP located within a planning area, a demonstration that a connection to the regional facility is not available.

D. For a regional WWTP, a water quality management plan that is in compliance with 401 KAR 5:006.

-1- DEP 7071-W1 (4/2018)

IV. DESIGN CONSIDERATIONS

A. PLANS AND SPECIFICATIONS.

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 specifications submittals shall meet on of the following options:

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 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 WWTP design capacity is greater than 10,000 gpd or if the sewer lines associated with the WWTP will become part of a sewer system served by a regional facility. [Section 6]

P.E.’s Name: Firm:

Street Address:

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 WWTP’s design capacity is greater than 10,000 gpd, or 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. Provide the following design capacities, in million gallons per day or pounds per day. [Section 3]

Average Daily Flow: MGD Influent BOD: lb/day

Peak Daily Flow: MGD Influent SS: lb/day

Peak Hourly Flow: MGD Influent NH3-N: lb/day

E. Design Criteria. Provide the following information (use additional pages, as necessary). Place a check (����) by the items included in the application or an N/A if the item is not applicable to the project.

1. A schematic drawing of the facility layout and explanation of the proposed facility and method of operation. [Section 3]

2. WWTP’s Reliability Category, Grade A, B, or C: . Include a detailed description of the reliability measures that will be used for the WWTP. [Sections 3 and 13]

3. A discussion of the design criteria used to size the unit processes. [Section 3]

F. LABORATORY SERVICES. Give name of laboratory that will provide services for self-monitoring and process control. [Section 3]

Firm Name:

Street Address:

G. SITE LOCATION. 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. Include a plat or survey clearly indicating the site’s boundaries, position of proposed facility in reference to the boundaries, and position of dwellings within 200 feet of the WWTP. [Section 3]

2. If an open-top WWTP is closer than 200 feet to the closest dwelling, include what structure or other measures will be used for noise and odor control. [Section 4]

3. For a WWTP with a spray irrigation system, if the distance from the spray field to the property boundary is less than 20 feet, include what protective measures will be used to inhibit spray from crossing property boundary. [Section 21]

H. 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. If modifying or replacing an existing WWTP or sewer line, 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]

2. A Sludge Management Plan for WWTPs, including the sludge processing method and how sludge will be ultimately disposed. [Section 3]

3. If the discharge point does not coincide with a blue line on a USGS map, a copy of a recorded deed, recorded other right of ownership, or recorded right of easement for a corridor to the nearest blue line stream. [Section 3]

4. A description of and detailed specifications for the flow measuring device. [Section 7]

5. If the WWTP discharges to a sinkhole or sinking stream, a plan for a groundwater tracer study (or a previously conducted groundwater tracer study). [Section 4]

V. SEWER LINES

Include the following items for projects that include sewer lines. If project is for only a WWTP, skip to next section. Place a check (����) by the items that are included in this application or N/A if the item is not applicable to the project.

A. If the project includes a pump station, the pump performance curve. [Section 8]

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

C. A demonstration that the sewer system has adequate capacity to treat the current and the anticipated flow to the WWTP and that the sewer system is not subject to excessive infiltration or excessive inflow. [Section 8]

D. A demonstration that the WWTP has adequate capacity to transport the anticipated flow to the WWTP and the WWTP is not subject to excessive infiltration or excessive inflow. [Section 8]

VI. OTHER REQUIRED APPLICATIONS

A. If the WWTP has a discharge, complete and file with this application: KPDES Application (KPDES Form 1); and Form A, B, C, or Short Form C, as applicable.

B. If the WWTP does not have a discharge, complete and file with this application the “No Discharge Operating Permit

Application, Form ND.”

VII. 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]

WWTP Category: Amount: $

Sewer Line Category: Amount: $

Total Amount: $

Pete Cloutier

CHECK

Pete Cloutier

CHECK

Pete Cloutier

CHECK

VIII. 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