Attachment E - Utility Permit - P602.pdf

UTILITY CONNECTION PERMIT APPLICATION Tracking #:___________

SECTION A - GENERAL INFORMATION

1. Requesting Activity: ____________________________________________________

2. Point of Contact: _____________________ Phone Number: ___________________

3. Project Location: _______________________________________________________

4. Type of Work: (Check all that apply.)

New Construction Building Addition Renovation

Demolition/Utility Disconnection Repair Utility Upgrade

5. Work will involve the following utilities: (Check all that apply.)

Water Sewer Electric Steam Gas

a. If Sewer is checked, will the connection be permanent or temporary?

Permanent Temporary (Proceed to question 6)

b. If a permanent connection is required and this project involves construction, contact the NAVFAC XXXXXX Environmental Business Line (Code

EV) to determine if Certificate to Construct/Certificate to Operate

(CTC/CTO) is required before proceeding.

6. Work to be performed by:

ROICC Contract NAVFAC XXXXXX Maintenance Department

Contract NAVFAC XXXXXX Utilities and Energy

Management Product Line

Other: ______________________________________________________________

7. Contract Title: ________________________________________________________

Contract/J.O./MAXIMO Number: ______________Drawing Number: _____________

NAVFAC NAVFAC XXXXXX Design Activity Other:____________

NOTE: Submit a complete set of drawings with the application. Include specifications if available.

SPECIFICATIONS INCLUDED: YES NO

DESIGN CALCULATIONS INCLUDED: YES NO

8. Designed by Firm/Activity: _____________________________________________

Point of Contact: _____________________________ Phone: _________________

9. Submitted by: (This is usually the Engineer in Charge (EIC) or AIC.):

Name: __________________________ Signature: __________________________

Title: __________________ Request Date: ________ Phone: __________

10. Reviewed by: __________________________ Date: ________

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NECC

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LITTLE CREEK

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RICHARD HOYT

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UMC COVER BOAT AND MAINTENANCE FACILITY (P602)

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G3CGFN

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NAVFAC MIDLANT

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ZACHARY STACY

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RON SILVA

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SUPERVISORY

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DESIGN MANAGER

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TBD

SECTION B - WATER

PART A - DOMESTIC WATER SERVICE CONNECTIONS

Complete the following for all domestic water service connections to water distribution system lines.

1. Number of Domestic Water Service Connections

(a) Existing service connections disconnected from water line __________

(b) New service connections connected to water line ___________

2. List the following for all new domestic water service connections to water distribution system lines. See Instructions for clarification.

(a) Pipe Size(s) _________________________________________

(b) Pipe Material(s) _________________________________________

(c) Pipe Class or Schedule _________________________________________

(d) Required Capacity (in gpm) _________________________________________

(e) Required Pressure (in psi) _________________________________________

(f) Meter Size(s) _________________________________________

(g) Meter Type(s) _________________________________________

(h) Backflow Preventer (Yes/No) _________________________________________

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TYPE K COPPER

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CLASS 350

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POSITIVE DISPLACEMENT

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YES

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BASED ON DEMAND

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BASED ON DEMAND

PART B - FIRE PROTECTION (HIGH PRESSURE/NON-POTABLE) WATER SERVICE

CONNECTIONS

Complete the following for all fire protection (high pressure/non-potable) water service connections to fire protection system lines.

1. Number of Fire Protection (High Pressure/Non-Potable) Water Service

Connections

(a) Number of existing service connections disconnected from fire protection line _________

(b) Number of new service connections connected to fire protection line

2. List the following for all new fire protection (high pressure/non-potable) water service connections to fire protection system lines. See

Instructions for clarification.

(a) Pipe Size(s) ________________________________________

(b) Pipe Material(s) ________________________________________

(c) Pipe Class or Schedule ________________________________________

(d) Required Capacity (in gpm) _________________________________________

(e) Required Pressure (in psi) _________________________________________

(f) Backflow Preventer (Yes/No) _________________________________________

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DUCTILE IRON

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YES

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CLASS 350

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SECTION C - SANITARY SEWER

PART A - SANITARY SEWER LATERAL CONNECTIONS

Complete the following information for work involving all sanitary sewer lateral connections to sanitary sewer mains.

1. Number of Sanitary Sewer Laterals

(a) Existing laterals disconnected from sanitary sewer main __________

(b) New laterals connected to sanitary sewer main __________

2. List the following for all new sanitary sewer lateral connections. See

Instructions for clarification.

(a) Pipe Size(s) _________________________________________

(b) Pipe Material(s) _________________________________________

(c) Pipe Class or Schedule _________________________________________

(d) Total Added Design Capacity (gpm)____________________________________

3. Type of Discharge from New Sanitary Sewer Laterals

(a) Building Type: (Check all that apply)

Office Residential Housing Recreational

Warehouse Food Service Fuel Depot

Commercial Barracks Trng. Facility

Medical Industrial Aircraft Hangar

Other (Specify)________________________________

(b) Indicate below any of the operations occurring in the above buildings: (Please check all that apply. If none of these apply, check N/A.)

N/A

Food Preparation Operations

Photo Processing or X-Ray Operations

Laboratory or Clinics

Industrial Laundry or Dry Cleaning

Printing Operations (other than copy machines for office use)

Handling or Collecting Used Oils, Solvents, Degreasers, or HW

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PVC

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SCHEDULE 40

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PART B - SANITARY SEWER MAINS

Complete the following information for work involving all sanitary sewer mains.

1. Number of sanitary sewer manholes abandoned __________

2. Number of sanitary sewer manholes installed __________

3. Linear feet of sanitary sewer main abandoned __________

4. Linear feet of sanitary sewer main installed __________

5. List the following for all new sanitary sewer mains:

(a) Pipe Size(s) _____________________________________________________

(b) Pipe Material(s)_____________________________________________________

(c) Pipe Class or Schedule_______________________________________________

PART C - SANITARY SEWER PUMP STATIONS

Complete the following information for work involving all sanitary sewer pump stations.

1. Number of sanitary sewer pump stations abandoned __________

2. Number of sanitary sewer pump stations installed __________

3. Number of pumps installed at each pump station _________________________

4. Size of each pump installed ____________________________________________

5. Attach details for pump station cut sheets, pump/ system curves, visible and audible alarms/ channels, bypass pump connections, valve and check valve connections, and wet well level monitoring systems.

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