HomeMy WebLinkAboutSP-22-004 - Supplemental - 0510 Shelburne Road (5)
CITY OF SOUTH BURLINGTON
APPLICATION for WASTEWATER ALLOCATION
*Items marked with an asterisk must be filled in by ALL applicants
*APPLICANT INFORMATION
Applicant: ______________________________________________
Contact Person: ________________________________________________
Mailing Address: _______________________________________________
_______________________________________________
Telephone & Fax for Contact Person: __________________________________
Property Owner Name (if not applicant): _______________________________
Property Owner Mailing Address: ____________________________________
____________________________________
*Physical Location of Project: ________________________________
__________________ ______________________
*Signature of Applicant *Signature of Property Owner
(Both applicant and property owner MUST sign the application!)
*Project Information
If the project is a single-family home, please check one: ____New ____Existing
If not a single-family home, project name: __________________________
*Application or Permit Numbers: (from Planning & Zoning office)
#____-____-____
#____-____-____
#____-____-____
Engineer’s Information for flows over 1,000 gpd
Name of Engineer: ____________________________________________
Firm: _____________________________________________________
Mailing Address: _____________________________________________
Phone & Fax: ________________________________________________
PE License #: ________________________________________________
FOR INTERNAL USE ONLY
WWA Permit #___-____
510 Shelburne Road
Bacon St. Commercial
Jennifer Desautels, P.E.
Trudell Consulting Engineer
478 Blair Park Road
802-879-6331
8917
Champlain Oil Company, LLC
Bryan Cairns
45 San Remo Drive
South Burlington, VT 05403
802-864-5380
Champlain Oil Co.
45 San Remo Drive
South Burlington, VT 05403
DocuSign Envelope ID: 4428644F-F9F6-4A6D-B299-A7531F7D7E48
*Flow Calculations
(You may substitute an engineer’s calculation or letter for the information requested
below)
For residential projects, list number of bedrooms and units requested:
Number of
Bedrooms
Number of Units
X
Gallons per day
per unit =
Total Flows
1 7 140
2 or more 2 210
TOTAL
Notes: ___________________________________________________
________________________________________________________
For commercial and industrial projects, list existing and proposed tenants, uses and
flows:
Tenant/ Type of use Number of Flows per Other Total
Business seats, SF, etc X unit Adjustments Flow
TOTAL
*Total development wastewater flow requested: ________gallons per
day
Flow characteristics (for commercial and industrial projects)
Volume:
____________________________________________________________
__________________________________________________
Flow rate:
____________________________________________________________
__________________________________________________
Strength:
____________________________________________________________
__________________________________________________
Commercial/ Office Space 25 Employees x 15 GPD/Employee = 375 GPD
Short Order Restaurant 18 Seats x 40 GPD/Seat = 720 GPD
Short Order Restaurant 5 Employees x 15 GPD/Employee = 75 GPD
Seven 1 Bedroom Apartments 7 x 1 Bedroom x 140 GPD/Bedroom = 980 GPD
Two 2 Bedroom Apartments 2 x 210 GPD/Unit = 420 GPD
2570 GPD
2570
980
420
1400
DocuSign Envelope ID: 4428644F-F9F6-4A6D-B299-A7531F7D7E48
Please do not write below this line
Application & Recording Fee received: _____________ ________
Name Date
Receiving Plant: ______Airport Pkwy _____Bartlett Bay
City Center District: ____Yes _____No
Approved by Water Pollution Control Department (Commercial and Industrial
Projects)
______________________ _____________
Director of Water Pollution Control Date
Preliminary allocation issued: (payment of fee is not required)
_______________________ _____________
Director of Planning and Zoning Date
Final allocation issued: (payment of fee is required, either in full or pro-rated for
projects with multiple zoning permits involved)
_______________________ _____________
Director of Planning and Zoning Date
Final allocation expires _________________with permit #____-____-____
(Date)
Zoning permit issued___________________with permit#____-____-____
(Date)
Associated WW connection permit (if applicable) #____-____-____
For extensions of Final Allocation Only
EXTENSION GRANTED ____________to______________
(Date) (Date of Expiration)
50% EXTENSION FEE PAID _________ $___________
(Date) (Amount)
DocuSign Envelope ID: 4428644F-F9F6-4A6D-B299-A7531F7D7E48