Attachment_E__Sanitary_Sewer_Extension_Form.pdf

Permit Application and Transmittal Form for Page 1 of 2 MAR 02 Sanitary Sewer Extensions and/or Changes (sewer-ext-application02.doc)

PERMIT APPLICATION and TRANSMITTAL FORM for

SANITARY SEWER EXTENSIONS

AND/OR CHANGES

NEW process for 2002!

COMPLETE APPLICATION BY PRINTING OR TYPING. PLEASE MAKE A PHOTOCOPY FOR YOUR RECORDS.

1. Title of Project (Plans and Specs): Sakatah Lake State Park, Sewer Connection: State Park to City of Waterville File No.: SPK00256.00.73.21/P-01-07

Developer/Owner: MnDNR - Division of Parks and Recreation Developer/Owner Address: 50499 Sakatah Lake State Park Road City: Waterville State: MN Zip: 56096 Phone: (507) 362-4438

2. Permittee: City of Waterville County: LeSueur Contact person: Rick Volbrecht Title: Utility Superintendent Phone: (507) 362-8835

3. Wastewater Treatment Facility (WWTF): Waterville Wastewater Treatment Plant Is the proposed sewer project in accord with the City or District Comprehensive Sewer Plan? Yes No

4. Specification of Current WWTF

1) Average wet weather design flow (AWW) 0.271 MGD

2) Annual average daily flow (past 12 months) 0.231 MGD

3) Average design flow (if AWW not available) MGD

4) Annual average influent CBOD5 (past 12 months) 133.6 mg/L

5. Estimated Flow Increase Initial Project: .001-.005 MGD Ultimate: .001-.005 MGD Basis for estimate: Actual water usage within park: .001-.005 MGD (flow values in peak season) (Less than 50 gpd in off-season)

6. Estimated BOD 5 Increase Initial Project: 5.34 #/day Ultimate: 5.34 #/day Basis for estimate: Lab results from grab samples taken during the peak camping season for 2000 & 2001

7. Location of Proposed Project : Facility is located in the quarter of the quarter of section Township of County Township #: 109N Range #: 23 East or West: West City: Waterville State: MN Zip: 56096 Address (or nearest intersection): 1101 Faribault Street

8. Nature of Area to be Served by the Proposed Project Residential: Number of New Homes: Number of Existing Homes:

Commercial/Industrial (Describe):

Other (Describe): Campground

9. Technical Agent or Consulting Engineer: Kim W. Waldof Title: Regional Engineer Name of firm or organization: MnDNR - Facilities & Operations Support Bureau Mailing Address: 1200 Warner Road, St. Paul, MN 55106 Phone: (651) 772-7989 Fax: (651) 772-7977

10. Has the project been reviewed in a previous Environmental Assessment Worksheet (EAW)? Yes No If yes, note the name of the project reviewed in the EAW, the responsible governmental unit, and the date of the negative declaration:

Name of the Project Reviewed in EAW: Date:

Responsible Governmental Unit: Date:

Date of the negative declaration:

11. Determination for the need of an EAW:

Is the ultimate design flow for the proposed project greater than 1,000,000 gpd? Yes No If yes, the preparation of an EAW is mandatory for this project.

MPCA USE ONLY

Application Number

Date Received Month Day Year

Check #

Fast Track? Yes No

Attachment E

Permit Application and Transmittal Form for Page 2 of 2 MAR 02 Sanitary Sewer Extensions and/or Changes (sewer-ext-application02.doc)

CERTIFICATION AND SIGNATURE

Federal regulations (Section 309(c)(2) of the Clean Water Act and State regulations (Minn. R. 7001.0070) require the authorized signer to be one of the following:

A. For corporation, a principal executive officer of at least the level of vice president;

B. For a partnership or sole proprietorship, a general partner or the proprietor, respectively; or C. For a municipality, State, Federal, or other public facility, either a principal executive officer or ranking executive official.

D. If the operator of the facility is different than the owner, both the operator and the owner according to items A to C.

“I certify under penalty of law that this document and all applicable design documents were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gathered and evaluated the information submitted. Based on my inquiry of the person, or persons, who manage the system, or those persons directly responsible for gathering the information, 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 and imprisonment.”

PRINTED NAME TITLE

AUTHORIZED SIGNATURE DATE

PRINTED NAME TITLE

(AUTHORIZED CITY REPRESENTATIVE)

PRINTED NAME Kim W. Waldof Reg No. 12721

(ENGINEER)

STATE TAX I.D. # FEDERAL TAX I.D. #

REMEMBER!

• DO NOT submit plans and specifications with this application unless required!

You must first complete the form and checklist titled: Design Certification for Sanitary Sewer Extension Plans and Specifications to determine if plans and specifications need to be submitted.

• No project construction may begin until you are in receipt of the required permit(s) issued by the MPCA and as defined by law under

Minn. Stat. § 115.07, subd.3.

• The project information packet you submit must contain ALL of the following items or it will be immediately returned:

1. This completed and properly signed Application Form.

2. The completed form and checklist titled: Design Certification for Sanitary Sewer Extension Plans and Specifications.

3. Plans and specifications (ONLY if required).

4. The required application fee ($240). Please make your check payable to the Minnesota Pollution Control Agency.

• Forms are available on the MPCA’s web site at: www.pca.state.mn.us. You can also contact the MPCA’s Customer Assistance

Center at (651) 297-2274 (Metro or outside MN) or toll free at (800) 646-6247 to request forms or ask questions.

• Send the project information packet to: Minnesota Pollution Control Agency, 520 Lafayette Road, St. Paul, Minnesota, 55155-4194 ATTN: Sanitary Sewer Extensions, REM, Metro.

Minnesota Pollution Control Agency Water Quality Division Point Source Section 520 Lafayette Road North St. Paul, Minnesota 55155-4194 http://www.pca.state.mn.us/