j14septic.xls

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&CATTACHMENT J14

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MBD01185B88.pdf

ADEM Form 468 1/06 m2

ADEM CLASS V UNDERGROUND INJECTION CONTROL

(UIC) PERMIT APPLICATION FORMAT

FOR DRAINAGE FIELD OR INJECTION WELL INSTALLATIONS

A. All Class V Permit Applications must contain the information listed below. Section A.I must be completed by a Professional Engineer licensed in the state of Alabama. Section A.II must be completed by a Professional Geologist licensed in the State of Alabama. If additional information is required, it will be requested.

AS A MINIMUM, THE FOLLOWING INFORMATION MUST BE PROVIDED:

I. General Information

1. Name and address of drainage field or injection well owner,

2. Name, address and phone number of facility contact,

3. Name of facility, address and physical location of facility, also provide latitude and longitude of facility. (Example: Montgomery County, Highway 31 S., 2 miles from Montgomery City Limits, Lat. Long. ).

4. Location of septic tank and/or treatment system, sampling system, drainage field and injection well(s). Include all that apply. (Attach a location plan and a topographic map of the area.)

(a) On plat or plan include the distances in footage from the following items if applicable:

(1) houses or buildings on property;

(2) property lines;

(3) surface water;

(4) any natural or manmade drainage course;

(5) any potable water supply lines;

(6) any structural feature not listed above which might affect or be affected by the effluent disposal field or injection well.

(b) If proposing drainage field disposal, include percolation rates and test methods. On the plat or plan include the percolation test locations,

(c) Describe soil characteristics in the shallow subsurface and give locations of borings on the plat or plan,

(d) Provide depth to groundwater (the first saturated zone). A physical determination for the presence or absence of groundwater must be conducted. If groundwater is not encountered within 10 feet from the surface, estimate groundwater depth by consulting the appropriate reference literature. Groundwater must be a minimum of five (5) feet below the field line trench.

(e) Include property dimensions on plan or plat.

5. Design and construction specifications of the septic tanks, if applicable. Include the following:

(a) materials of construction;

(b) drawing of septic tank including the following:

(1) length and width of septic tank;

(2) total depth of septic tank;

(3) liquid depth and air space in septic tank;

(4) liquid capacity of the tank.

6. Design of the treatment system or additional treatment systems not outlined in item 5.

Provide all plans, specifications, and other pertinent information. Please note that Laundromats are required to install a lint screening system, plans for which must be submitted.

7. Description of fluid to be injected. Include the following:

(a) description of the process generating the wastewater;

(b) maximum volume flow per day;

(c) maximum instantaneous flow rate;

(d) pollutants added;

(e) material safety data sheets of all chemicals used in process;

8. Construction details of the effluent disposal field(s), if applicable. Include the following:

(a) plan or plat showing design and location of field;

(b) amount of line to be used in linear feet;

(c) construction of the field trenches including width, depth, minimum distances between trenches, and lateral length of the field;

(d) size and description of pipes and fittings to be used.

(e) construction of the header line;

(f) percentage of slope if field lines to be laid in a sloping area;

9. Construction details of the injection well(s), if applicable. Include the following:

(a) depth of well(s);

(b) screened interval;

(c) elevation of top of casing;

(d) construction details;

(e) location of wells on plat or plan;

10. Design of the sampling system. The permit will require a means of sampling the wastewater after treatment and prior to injection.

11. An inventory of all known public or private drinking water wells within 0.5 miles of the drainage field. Include a map or drawing showing the location of these wells.

12. Construction details of a monitoring well down gradient of the injection field for the purpose of monitoring groundwater quality for all car washes, truck washes, industrial discharges, and as otherwise specified by the Department. Include proposed location and construction plan for a monitoring well and design specifications addressing the following:

(a) Monitoring well screening in the upper most saturated zone. The well screen should be of sufficient length to account for seasonal fluctuations in the water table and affects of the injection field.

(b) Sealing of the annulus around the well casing above the well screen with bentonite to prevent the passage of surface water or injection field water.

(c) Concrete protective pad around the base of the well, a metal protective casing, and a locking cap.

(d) Routing of all surface water away from the monitoring well's surface installation.

(e) Plans for purging and sampling the monitoring well. The permit will require the monitoring well be constructed and sampled prior to injection and annually thereafter.

13. A request for the issuance of an Underground Injection Control (UIC) Permit signed by the owner. In the case of a company, corporation, or other institution, a responsible official such as a partner, corporate official, or director may sign the application.

II. HYDROGEOLOGIC SITE EVALUATION

1. Complete the attached form #531: “ADEM HYDROGEOLOGY UNIT SITE

EVALUATION REPORT FORM.”

2. Include the following attachments:

(a) Boring log(s) for site

(b) Topographic Map with site location marked

3. Include a cover letter summarizing the site information.

B. Submit the application to:

UIC Program Alabama Department of Environmental Management Post Office Box 301463 Montgomery, AL 36130-1463

For package delivery:

1400 Coliseum Blvd.

Montgomery, AL 36110

C. INCLUDE THE APPROPRIATE FEE WITH THE APPLICATION. USE A CHECK OR MONEY

ORDER PAYABLE TO "ALABAMA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT" OR

"ADEM." THE DEPARTMENT DOES NOT CONSIDER A PERMIT APPLICATION TO BE

COMPLETE WITHOUT THE RECEIPT OF THE APPROPRIATE PERMIT FEE.

ADEM HYDROGEOLOGY UNIT SITE EVALUATION REPORT FORM

HYDROGEOLOGIST CONDUCTING EVALUATION: DATE OF SITE VISIT

OTHERS PRESENT DURING THE EVALUATION:

FACILITY NAME:

ADDRESS:

CITY: ZIP: COUNTY:

CONTACT: TELEPHONE:

TYPE OF INSPECTION

TOPO QUADRANGLE / SECTION / TOWNSHIP / RANGE LATITUDE & LONGITUDE:

CHECKLIST:

PITS EXCAVATED AND LOGGED ( )

DEPTH TO GROUNDWATER DETERMINED ( ) FEET BELOW SURFACE

DEPTH TO BEDROCK DETERMINED ( ) FEET BELOW SURFACE

WATER USAGE SURVEYED ( ) # OF RESIDENTIAL WELLS

SAMPLES COLLECTED ( ) CLOSEST RESIDENTIAL WELL

# OF PUBLIC SUPPLY WELLS

DISTANCE TO CLOSEST PUBLIC WELL

TOPOGRAPHIC DESCRIPTION:

PHYSIOGRAPHIC PROVINCE:

SCS SOIL TYPES:

GEOLOGIC FORMATION:

SURFACE WATER BODIES:

ADEM DIVISION 6 RECEIVING STREAM CLASSIFICATION:

USGS FLOOD PRONE AREA:

WELL HEAD PROTECTION AREA:

SITE HYDROGEOLOGIC DESCRIPTION: (attach additional page(s) as necessary)

NOTES:

ACCESS INFORMATION

EXPLORATORY PIT or BORING LOGS: Refer to Site Location Map for locations.

Pit 1:

Pit 2:

Pit 3:

(Complete and add additional pit/boring logs as necessary)

MBD0118751D.pdf be completed by a Professional Geologist licensed in the State of Alabama. If additional information is

(3) surface water;

(4) any natural or manmade drainage course;

not encountered within 10 feet from the surface, estimate groundwater depth by

(c) maximum instantaneous flow rate;

(c) elevation of top of casing;

Post Office Box 301463 Montgomery, AL 36130-1463

For package delivery:

MBD01187A84.pdf be completed by a Professional Geologist licensed in the State of Alabama. If additional information is

(3) surface water;

(4) any natural or manmade drainage course;

not encountered within 10 feet from the surface, estimate groundwater depth by

(c) maximum instantaneous flow rate;

(c) elevation of top of casing;

Post Office Box 301463 Montgomery, AL 36130-1463

For package delivery:

MBD0118617E.pdf be completed by a Professional Geologist licensed in the State of Alabama. If additional information is

(3) surface water;

(4) any natural or manmade drainage course;

not encountered within 10 feet from the surface, estimate groundwater depth by

(c) maximum instantaneous flow rate;

(c) elevation of top of casing;

Post Office Box 301463 Montgomery, AL 36130-1463

For package delivery:

MBD0118290A.pdf be completed by a Professional Geologist licensed in the State of Alabama. If additional information is

(3) surface water;

(4) any natural or manmade drainage course;

not encountered within 10 feet from the surface, estimate groundwater depth by

(c) maximum instantaneous flow rate;

(c) elevation of top of casing;

Post Office Box 301463 Montgomery, AL 36130-1463

For package delivery:

MBD011854B0.pdf be completed by a Professional Geologist licensed in the State of Alabama. If additional information is

(3) surface water;

(4) any natural or manmade drainage course;

not encountered within 10 feet from the surface, estimate groundwater depth by

(c) maximum instantaneous flow rate;

(c) elevation of top of casing;

Post Office Box 301463 Montgomery, AL 36130-1463

For package delivery: