HomeMy WebLinkAboutPermit Wastewater Allocation WWA-21-152CITY 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 #___-____
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*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
1 140
2 or more 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:
____________________________________________________________
__________________________________________________
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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)
Justin
Rabidoux
Digitally signed by Justin
Rabidoux
DN: cn=Justin Rabidoux
Date: 2021.08.30 13:29:42 -04'00'
3/14/22
x
Thomas
DiPietro
Digitally signed by Thomas DiPietro
DN: cn=Thomas DiPietro, o=City of
South Burlington, ou=Department of
Public Works,
email=tdipietro@sburl.com, c=US
Date: 2022.03.14 16:31:46 -04'00'
D. Hall 02/24/2022
03/04/2022 ZP 22 043
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