MPCA Sanitary Sewer Extension Permit Application
NEW process for 2oo2!
MPCA USE ONLY
Application Number
Date Received
1-::- Month Day Year
Check #
Fast Track? DYes DNo
~
-- -
Minnesota
Pollution
Control
Agency
PERMIT APPLICA TION and TRANSMITTAL FORM for
SANITARY SEWER EXTENSIONS
AND/OR CHANGES
COMPLETE APPLICA T/ON BY PRINTING OR TYPING. PLEASE MAKE A PHOTOCOPY FOR YOUR RECORDS.
1. Title of Project (Plans and Specs): lo'T\JS ~
Developer/Owner: (2ot-l ~ - ~ e~ 5,-rIA..-tE.. ~
Developer/Owner Address: \ol~"\ ~~'l't.k~ ~~.
City: ~~u~<<i:.~ State: t-t...,) Zip: C5~3C>S Phone: (1.b~) ~bS -03.55
2. Permittee: Ll-t'i Or ~~~ County: ~'\Je-e......
Contact person: PAVI_ OFU,ME Title-: "\::>\(2.... ~o~u.t. wof2..'L~l Phone: flS2.) '2-'l..1- \ \(:,C\
CL~ ~b'~~
3. Wastewater Treatment Facility (WWTF): 13'-"'1;; ~
Is the proposed sewer project in accord with the City or District Comprehensive Sewer Plan? [gL Yes 0 No
4. Specification of Current WWTF
1) Average wet weather design flow (A WW)
2) Annual average daily flow (past 12 months)
3) Average design flow (if A WW not available)
4) Annual average influent CBOD5 (past 12 months)
5. Estimated Flow Increase Initial Project:
Basis for estimate: 3.3. Ci'-f' I ~ )
c> MOD
100 (;oM IlM>l~
Ultimate: o. ex:> 3
p,~
MOD
MOD
MOD
mgIL
MOD
6. Estimated BOD s Increase
Basis for estimate: t:>. "
. Initial Project: 0
\-e.S (e....P I b "'1
#/day
Ultimate:
4.$
#/day
7. Location of Proposed Project:
Township ~~ ~-..c;.~
Township #: \\b
City: r.&.\~~~~
Address (or nearest intersection):
Facility is located in the s€. quarter of the suJ
of ('~~
'2-~ East or West: ~
State: J.-\.tJ Zip: ~!> '!. \ 1
~c....""t\~ 0 F ~~e;{L. ~ R.t> - .s.. Po')(.
quarter of section \
County
Range #:
-u,\lA. ba.....
8. Nature of Area to be Served by the Proposed Project
Residential: Number of New Homes: e
CommerciallIndustrial (Describe): JJ,...
Other (Describe): #oJ 6-
9. Technical Agent or Consulting Engineer: ~...v~ O~o Title: ~~Sl~Jlo.'- WC:.~.
Name of firm or organization: (')~D ~<;,oc..\. Clo.-~ ~c:..
Mailing Address: ~ WeFz,-c I> \ ~ \<;.. CJ"t'-.1 ca.",. R v FC::~ t M..N C;; So ~ l~
Phone: (?t"~) CoaCO"l.--..\-"'1l..." Fax: ((b~) (Q&1....-3S"2.."L..
10. Has the project been reviewed in a previous Environmental Assessment Worksheet (EA W)? 0 Yes ~No
If yes, note the name of the project reviewed in the EA W, the responsible governmental unit, and the date of the negative declaration:
Name of the Project Reviewed in EAW: Date:
Responsible Oovernnlental Unit: Date:
Date of the negative declaration:
Number of Existing Homes:
D
11. Determination for the need of an EA W:
Is the ultimate design flow for the proposed project greater than 1,000,000 gpd? 0 Yes 6aNo
If yes, the preparation of an EA W is mandatory for this project.
Permit Application and Transmittal Form for
Sanitary Sewer Extensions and/or Changes (wq-wwprm7-15)
Page 1 of 2
MAY 03
CERTIFICATION AND SIGNATURE
Federal regulations (Section 309(c)(2) of the Clean Water Act and State regulations (Minn. R. 7001.0070) require the authorized
signer to be one of the following:
A. For corporation, a principal executive officer of at least the level of vice president;
B. For a partnership or sole proprietorship, a general partner or the proprietor, respectively; or
C. For a municipality, State, Federal, or other public facility, either a principal executive officer or ranking executive official.
D. If the operator of the facility is different than the owner, both the operator and the owner according to items A to C.
., certify under penalty of law that this document and all applicable design documents were prepared under my direction or supervision in
accordance with a system designed to assure that qualified personnel properly gathered and evaluated the information submitted. Based
on my inquiry of the person, or persons, who manage the system, or those persons directly responsible for gathering the information, the
information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant
penalties for submitting false information, induding the possibility of tine and imprisonment.
PRINTED NAME
TITI.E
AUTHORIZED SIGNA lURE
DATE
PRINTED NAME
TITLE
AUTHORIZED SIGNAlURE
DATE
(AUTHORIZED CIlY REPRESENTATIVE)
PRINTED NAME P Attt. 0770
AUTHORIZEDSIGNAlURE ~C!"~
(ENGINEER)
Reg No. rtbt;? ~
DATE 8>' d P-o 7
STATE TAX I.D. #
FEDERAL TAXLD.#
REMEMBER!
· DO NOT submit plans and specifications with this application unless required!
You must first complete the form and checklist titled: Design Certification for Sanitary Sewer Extension Plans and Specifications
to determine if plans and specifications need to be submitted.
· No project construction may begin until you are in receipt of the required permit(s) issued by the MPCA and as defined by law under
Minn. Stat. ~ 115.07, subd.3.
· The project information packet you submit must contain ALL of the following items or it will be immediately returned:
I. This completed and properly signed Application Form.
2. The completed form and checklist titled: Design Certification for Sanitary Sewer Extension Plans and Specifications.
3. Plans and specifications (ONLY if required).
4. The required application fee ($240). Please make your check payable to the Minnesota Pollution Control Agency.
· Forms are available on the MPCA's web site at: www.pca.state.mn.us. You can also contact the MPCA's Customer Assistance
Center at (651) 297-2274 (Metro or outside MN) or toll free at (800) 646-6247 to request forms or ask questions.
· Send the project information packet to: Minnesota Pollution Control Agency, 520 Lafayette Road, St. Paul, Minnesota, 55155-4194
ATTN: Sanitary Sewer Extensions, REM, Metro.
Permit Application and Transmittal Form for
Sanitary Sewer Extensions and/or Changes (wq-wwprm7-15)
Page 2 of 2
MAY 03
~
Minnesota
Pollution
Control
Agency
Design Certification for Sanitary Sewer
Extension Plans and Specifications
MPCA USE ONLY
Application Number
SE# I
Fast Track? YES
NO
Permittee:
\"t' ....,
01=="
~foqJ+-\M.~~
~uc::. W~S
Title of Plans and S ecifications:
Location of Pro. ect ma' or intersection: ~ee..... ~ ~t).
All sanitary sewer extensions shall be designed according to the latest version of the following
recommendations, specifications, and guidelines (specific MPCA guidelines take precedence over other
documents):
Recommended Standardsfor Wastewater Facilities, Great Lakes - Upper Mississippi River
Board of State and Provincial Public Health and Environmental Managers. (Ten States
Standards)
Standard Utilities Specification, City Engineers Association of Minnesota.
Design Flow and Loading Determination Guidelines, Minnesota Pollution Control Agency
Fast Track Review Process
· Answer questions no. 1-44 below
· If both questions no. 23 and 46 are answered YES or NA:
. sign the Fast Track Certification Statement if applicable;
. attach this completed form to the Sanitary Sewer Extension Permit Application; and
· do not submit plans and specifications (plans and specifications for some projects may be
required to be submitted for review as part of a random audit to verify compliance
with applicable standards).
Detailed Review Process (This process may reQuire additional time for completion)
· Answer questions no. 1-44 below
· If either question no. 23 or 46 are answered NO:
. do not sign the certification statement below;
. sign the Statement for Detailed Review;
. attach a copy of this completed form to the Sanitary Sewer Extension Permit Application;
. provide justification for not following the specified recommendations; and
· submit plans and specifications for review and approval.
Design Certification for Sanitary Sewer Extension
Plans and Specifications Form (wQ-wwprm7-13)
Page 1 of 4
JUL 02
Design Flow:
I. What is the er ca ita r da desi flow?
2. If the design flow is less than 100 gallons per person per day, is the total based on an analysis of actual existing per
ca ita flow to the treatment facili ?
3. What is the desi eakin factor?
Sewer Pipe:
Yes No NA
@ 0
MOO
~ 0
o 0 /K]
0 o lEI 9.
0 0 gj 10.
0 0 f(] II.
III 0 12.
OCJ 0 0 13.
[l
~
o
o
5. Are all sewers desi ed without an overflow or b ass oint?
6. Are all vi sewers at least 8 inches diameter? Answer NA onl if there are no vi sewers
7. Are all sewers sufficiently deep to receive wastewater from basements and to prevent freezing or
is insulation rovided for sewers that are not laced at a de th to revent freezin ?
8. If there are sewers that cross or enter any water body, has the Department of Natural Resources
been contacted to determine if they will require a permit for construction? (Answer NA only if
there are no sewers located in a water bod ?
Do the design plans and specification contain specific size and location requirements for reaction
blocking or pipe restraint to withstand water hammer and other cyclic reversal of stresses
associated with lift station 0 ration? Answer NA onl ifthere are no res sure sewers
Is there an air relief valve shown at all high points in force mains? (Answer NA only if there are
no ressure sewers
Are grinder pumps or other solids removal equipment included for any force main that is less than
4 inches in diameter? Answer NA onl if there is no ressure sewer
Are all sewers designed with mean velocities when flowing full, of at least 2.0 feet per second,
based on Mannin 's formula usin and "n" value ofO.013?
Is the slope of 8-inch diameter gravity sewer at least 0.40%; 10-inch diameter sewer at least
0.28%; 12-inch diameter sewer at least 0.22%; 14-inch diameter sewer at least 0.17%; IS-inch
diameter sewer at least 0.15%; 16-inch diameter sewer at least 0.14%; and 18-inch diameter sewer
at least 0.12%? The pipe diameter and slope shall be selected to obtain the greatest practical
velocities to minimize settling problems. Oversizing sewers to achieve flatter slopes should not be
done. Ifproposed slopes are less than those listed above, what is the depth offlow and velocity of
flow at the average wet weather flow and peak hourly wet weather flow for affected pipe sections?
AWWflow (mgd)= Depth of flow = (ft.) Velocity= (fps)
PHWW flow (mgd) = Depth of flow = (ft.) Velocity= (fps)
If sewer grades are less than those listed above, sedimentation problems, frequent sewer maintenance, and
backups may result. All sewers with a slope less than the minimums listed above be cleaned at least once
per year to ensure problems to not develop and to develop a site specific maintenance interval. (Answer
N/A onl ifno vi sewer.
14. Are individual service connections to the sewer designed to be water tight and do not protrude into
the sewer?
IS. Are all gravity and pressure sewer pipes and water supply pipe separated horizontally by at least
10 feet and vertically by at least 1.5 feet when crossing?
o For gravity sewers only, ifit is not practical to maintain a 10 feet horizontal separation, is
water main in a separate trench or on an undisturbed earth shelf located on one side of the sewer
and at an elevation so the bottom ofthe water main is at least 18 inches above the top of the
sewer?
o For gravity sewers only, ifit is impossible to obtain the proper horizontal and vertical
separations, are both water and sewer pipe constructed of sIip-on or mechanical joint pipe
com I in with ublic water su I desi and construction standards?
Design Certification for Sanitary Sewer Extension
Plans and Specifications Form (wq-wwprm7-13)
Page 2 of 4
JUL 02
Sewer Pipe (Continued):
Yes No NA
~ 0 0 16.
~ 0 0 17.
KJ 0 0 18.
~ 0 0 19.
9J 0 0 20.
il 0 0 21.
~ 0 22.
~ 0 0 23.
Lift Stations:
Yes No NA
o ~
o 0
o 0
o 0 0
o 0 0
o 0
o 0
o 0
o 0
o 0
o
o 0
o 0
o 0
o 0 0
o 0 0
o 0 0
Are all manholes at least 48 inches in diameter? Answer NA onl if there are no manholes.
Are all manholes constructed to revent surface water run off from enterin throu h the cover?
Are drop manholes used at locations where the sewer pipe enters the manhole at an elevation of 24
inches or more above the manhole invert? (Answer NA only if sewer pipes enter at an elevation
less than 24 inches
Is the spacing between manholes 400 feet or less or if the spacing is greater than 400 feet, do
opemtion and maintenance personnel have access to adequate cleaning equipment that can
acconunodate the s acin? Answer NA onI if all ressure sewer.
Will a leakage test be performed to demonstmte watertightness of the sewer pipes?
What test method will be used?
Will a deflection test be performed on all plastic gravity sewer after the pipe has been in place for
at least 30-da s? Answer NA onl iftelevisin or other method is used instead.
Will sewer line televisin be rformed? Answer onl as YES or NA
Have uestions #5 through #22 been answered as YES or NA?
Does the ro' ect include an 'Work on a lift station? NO, 0 to uestion No. 46 and answer NA
24. Will the lift station be full 0 mtional and accessible durin a 25 ear flood?
25. Will the lift station structural, electrical and mechanical equipment be protected from physical
dama e durin at 100 ear flood?
26. Where high ground water conditions are anticipated, has the buoyancy of the lift station structure
been considered and adequate provisions made to protect the structures? (Answer NA only ifhigh
ound water conditions are not antici ated.
27. Are wet wells and dry wells completely sepamted and cornmon walls are gas tight? (Answer NA
onI if no d well is included
28. Are multiple pumps provided such that with any unit out of service, the remaining units have
ca aci to handle the desi eak hourI wet weather flow?
29. Are all um s ca able of assin s heres of at 3 inches in diameter?
30. Are all um suction and dischar eo Din at least 4 inches in diameter?
31. Are all electrical components in raw wastewater wet wells in compliance with National Electrical
Code r uirements for Class I Grou D, Division 1 locations?
32. There are no b ass or overflow i from the wet well?
33. Are suitable shutoff and check valves laced on the dischar e line of each
34. Are check valves located between the shutoff valve and the um ?
35. Are check valves placed in the horizontal position, except ball valves which may be placed
verticall ?
36. Are shutoff and check valves for submersible pump lift stations located in a sepamte valve pit? If a
se amte valve it is not rovided, are all valves easil accessible for maintenance?
37. If a dmin line is provided between a valve pit or dry well and a wet well, is the dmin line equipped
with a gas and water tight valve or extended below the low water level in the wet well to prevent.
en of hazardous cases to the valve it? Answer NA onl if a dmin line is not included
38. If continuous wet well ventilation is provided, are at least 12 complete air changes per hour
rovides? Answer NA onI if submersible urn lift station
39. If intermittent wet well ventilation is provided, are at least 30 complete air changes per hour
rovided? Answer NA onl if submersible urn lift station
Design Certification for Sanitary Sewer Extension
Plans and Specifications Fonn (wq-wwpnn7-13)
Page 3 or 4
JUL 02
Lift Stations (Continued):
Yes No NA
o 0 40.
o 0 41.
o
o
o
o
o
o
o
o
42.
43.
If continuous dry well ventilation is provided, are at least 6 complete air changes per hour
rovided? Answer NA onl if submersible urn lift station
If intermittent dry well ventilation is provided, are at least 30 complete air changes per hour for 10
minutes and 6 complete air changes per hour thereafter provided? (Answer NA only if submersible
um lift station
Are rovisions for flow measurement rovided? T e:
Are a sufficient number of running time meters provided to record when each pump is running and
when multi Ie urn s are runnin at the same time?
Is an appropriate alarm system provided to indicate power failure, pump failure, unauthorized
en , or other malfunction? T of alarm:
Are provisions included for emergency operation to prevent the bypassing or backup of sewage?
Emergency pumping capability may be accomplished by connection to at least two independent
utility substations, or by provision of portable or in-place electrical generation, or by portable
urn in ui ment? T e:
Have uestions #24 throu #46 been answered as YES or NA?
o
o
44.
45.
46.
o
o IPJ
Fast Track Certification Statement (Do not submit plans and specifications)
"I have answered Checklist items No. 23 and No. 46 above as YES or NA and hereby certify that the design plans and
specifications for this project, to the best of my knowledge, conform to the requirements listed above. I am aware that
there are significant penalties for submitting false infonnation. including the possibility of fine and imprisonment.
I hereby certify that this plan, specification, or report was prepared by me or under my direct supervision and that I am a
duly Licensed Professional Engineer under the laws of the state of Minnesota.
Signature:
Date:
Typed or Printed Name:
Registration Number:
Phone Number:
Address:
Statement for Detailed Review (plans and specifications must be submitted)
"I have answered NO to Checklist item No. 23 or No. 46 because the design does not conform with all of requirements in
the above listed standards, specifications, and guidelines"
Signature: Date:
List of standards, specifications, and l!uideline not complied with (attach additional pages if needed):
Section Number Justification for variation
Design Certification for Sanitary Sewer Extension
Plans and Specifications Form (wq-wwprm7-13)
Page 4 of 4
JUL 02