The URL can be used to link to this page

Home My WebLink AboutPermit Wastewater Allocation WWA-24-123 (2)Permit #: ______________ 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)