HomeMy WebLinkAboutPermit Wastewater Allocation WWA-24-124Permit #: ______________
City of South Burlington
Department of Public Works
104 Landfill Road
South Burlington, Vermont 05403
Tel: (802) 658-7961
Email: dpw@southburlingtonvt.gov
WASTEWATER ALLOCATION APPLICATION FORM – PART A
All requests for a wastewater allocation from the City of South Burlington must complete Part A.
Physical Location of the Project (Street Address): ___________________________________________
APPLICANT INFORMATION
Applicant: _____________________________________
Contact Person: ________________________________
Mailing Address: _______________________________
Phone Number: ________________________________
Email Address: _________________________________
PROJECT ENGINEER’S INFORMATION
Engineer’s Name: _______________________________
Firm Name: ___________________________________
Mailing Address: ______________________________
Phone Number: _______________________________
Email Address: ________________________________
(For office use only)
Permit #: ______________
EXISTING PERMIT INFORMATION
List all existing application or permit numbers from South Burlington planning and zoning office:
______________________________________
List any existing State of Vermont wastewater permits issued to this property:
____________________________________________
ADDITIONAL INFORMATION
Does the project include a residential use: Yes No
o If yes, you must complete Part B of this application form.
Does the project include a commercial or industrial Use: Yes No
o If yes, you must complete Part C of this application form.
Does the property already have an approved wastewater allocation: Yes No
o If yes, you must complete Part D of this application form.
Does your project already have a wastewater connection permit: Yes No
o If yes, please provide the wastewater connection permit number: __________________
o If no, you must submit a wastewater connection permit at the time of this application.
I certify that the information provided in the application form is accurate. I understand that this
allocation is subject to the conditions set forth in the City of South Burlington’s “Ordinance
Regulating the Use of Public and Private Sanitary Sewerage and Stormwater Systems” and I agree to
the general conditions and requirements, and any special conditions / restrictions included with this
permit.
___________________________________________ Date: ______________________________________
Applicant Signature
(For office use only)
Permit #: ______________
General Conditions and Requirements
The City of South Burlington “Ordinance Regulating the Use of Public and Private Sanitary Sewerage and Stormwater
Systems” requires anyone seeking allocation of the City’s uncommitted wastewater reserve capacity to obtain a final
allocation. All allocations are subject to the conditions set forth in the City’s ordinance. Obtaining a permit from the State of
Vermont does not satisfy requirements of requirements contained within the South Burlington ordinance and may be
required in addition to obtaining a final allocation from the City of South Burlington. Prior to issuance of a final wastewater
allocation the applicant must pay the appropriate fees. Fees for wastewater allocations are established by City Council and
are adjusted annually. For information on the current fees please reference the City of South Burlington web site at
www.southburlingtonvt.gov.
The City of South Burlington is not responsible for completing this form on behalf of applicants, or conducting the permit
research necessary for completion of this application. Applicants are expected to retain the engineering services necessary to
submit a completed form for review by the City of South Burlington. Developments generating over 1,000 GPD shall have
their allocations certified by a Vermont registered engineer.
Please Do Not Write Below This Line – For City Staff Use Only
Special Permit Restrictions / Conditions:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Summary of Allocation
•Requested New Residential Allocation from Part B: ________________________
•Requested New Commercial / Industrial Allocation from Part C: ________________________
•Existing Allocation from Part D: ________________________
•Total New Allocation Being Requested (B+C-D): ________________________
Receiving Plant: Airport Parkway Bartlett Bay
City Center District: Yes No
Preliminary Allocation Approval: (payment of fee is not required at this time)
___________________________________________ Date: ______________________________________
Signature of Director of Public Works or Designee
Fee Calculation: ______ (GPD of new allocation) * $_____ (allocation rate) = $________________
Final Allocation Approval: (payment of fee is required at this time)
___________________________________________ Date: ______________________________________
Signature of Director of Public Works or Designee
This final allocation expires on ____________ with ______________
(Date) (Permit #)
Zoning permit issued on ____________ with ______________
(Date) (Permit #)
(For office use only)
Permit #: ______________
WASTEWATER ALLOCATION FOR RESIDENTIAL USES - PART B
Wastewater Flow Calculations for Residential Uses
The required amount of allocation for a project shall be based on the Vermont Agency of Natural
Resources Wastewater System and Potable Water Supply Rules (current edition).
UNIT(S) INFORMATION
For residential projects, list the number of units requested by number of bedrooms per unit:
Number of
Bedrooms Number of Units
Gallons Per Day
per unit
Total Flows
(GPD)
1 140
2 or more 210
TOTAL
INFILTRATION SYSTEM INFORMATION
When a wastewater system includes a gravity sanitary sewer service line or collection system exceeding
500 feet in total length the project must include infiltration flow. Follow the procedures in the State of
Vermont Wastewater System and Potable Water Supply Rules to determine the amount of infiltration
that must be included in the allocation.
Total linear feet of wastewater pipe associated with this property: __________ LF
If total length of wastewater pipe is greater than 500 linear feet, use the table below to summarize pipe
size, length, and associated gallons per day of infiltration to be included in the allocation. If this
infiltration was approved in a previous final allocation, you may skip this section and provide that
information in the space provided after the table.
Pipe Diameter
(Inches)
Pipe Length
(Feet)
Infiltration Factor
(Gallons per linear foot)
Additional Infiltration
Flow (GPD)
TOTAL
(For office use only)
Permit #: ______________
PREVIOUS ALLOCATION
Was there a previously approved wastewater allocation from the City of South Burlington that included
an additional allocation related to infiltration from a gravity pipe system: Yes No
•If yes, please provide the wastewater allocation permit number: __________________
•If yes, please describe how this additional allocation was included / not included in the prior
permit:
TOTAL NEW ALLOCATION REQUESTED FROM PART B: __________ GPD
(For office use only)
Permit #: ______________
WASTEWATER ALLOCATION FOR COMMERCIAL AND INDUSTRIAL PROPERTY - PART C
Wastewater Flow Characteristics and Calculations for Commercial and Industrial Properties
In addition to the information below, you may provide additional calculations and information in a
letter attached to Part C.
EXISTING PRETREATMENT INFORMATION
Does the property include a kitchen used for commercial (i.e. non-residential) meal preparation: Yes No
Does the property have an existing grease trap: Yes No
Does the property have an existing oil / water separator: Yes No
Does the property have an existing sediment interceptor: Yes No
Does the property have an existing Grease, Oil and Sand Interceptor Permit from the City of
South Burlington: Yes No
•If yes, please provide the permit number: ______________
•If no, is a Grease, Oil and Sand Interceptor permit being submitted in conjunction with this
project: Yes No
Does the property have a commercial (i.e. non-residential) pool or hot tub: Yes No
Does the property currently provide pretreatment of wastewater before it is discharged to the South
Burlington system: Yes No
•If yes, please describe:
(For office use only)
Permit #: ______________
FLOW CHARACTERISTICS
Describe any industrial / manufacturing process that will take place on the property:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Will the project discharge wastewater that is likely to exceed a five-day Biochemical Oxygen Demand
(BOD) above what would be associated with a typical residential wastewater discharge (i.e. a BOD
above 300 mg/L): Yes No
Will the project discharge wastewater that is likely to exceed a Total Suspended Solids (TSS) above
what would be associated with a typical residential discharge (i.e. a TSS above 150 mg/L): Yes No
Will the project discharge wastewater that is likely to contain measurable levels of copper: Yes No
For commercial and industrial properties list the existing and proposed tenants, uses, and flows.
Information on how to calculate flows for commercial and industrial properties can be found in the
State of Vermont Wastewater System and Potable Water Supply Rules. Calculations must be based on
values included in the most current edition of the Rules.
Suite /
Unit Description of Use
NAICS
Code
Number of
Seats,
Square Feet,
Employees,
etc
Flow Per
Seat, Square
Feet,
Employee,
etc Adjustments Total Flow
(For office use only)
Permit #: ______________
Additional Notes / Comments:
TOTAL NEW ALLOCATION REQUESTED FROM PART C: __________ GPD
(For office use only)
Permit #: ______________
SUMMARY OF EXISTING WASTEWATER ALLOCATIONS - PART D
If the property was previously issued a final wastewater allocation, please include information in the
table below:
State / City Permit
Number*
Final Allocation
Issued by: Date of Issuance
GPD of Final
Allocation
South Burlington
State of Vermont
South Burlington
State of Vermont
South Burlington
State of Vermont
South Burlington
State of Vermont
South Burlington
State of Vermont
*You may attach copies of previously issued allocations to this application, but it is not required.
If the property was developed on January 1, 2007, but there is no record of a final wastewater
allocation, please provide a description of all uses (e.g. restaurant with 25 seats, veterinarian clinic with
5 employees and no animal boarding, etc) that were in place on the property on January 1, 2007.
City staff will review this information and contact you regarding the approved existing allocation for
the property.
Additional Notes / Comments:
TOTAL EXISTING ALLOCATION FROM PART D: __________ GPD
(For office use only)