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HomeMy WebLinkAboutSD-22-10 - Supplemental - 0500 Old Farm Road (27) 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 #___-____ *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: ____________________________________________________________ __________________________________________________ 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)