Sanitary Sewer Extension Permit Application® Minnesota Pollution
Control Agency
520 Lafayette Road North
St. Paul, MN 55155 -4194
Sanitary Sewer Extension
Permittee: City of Chanhassen
The permittee is the owner /operator, usually the municipality, of the proposed
sewer system or the system that the proposed project will connect to. Individual
service connection owners are not usually considered to be a permittee.
Title of project: Boulder Cove
Project proposer name: Lennar Corporation
Project proposer phone number: 952- 249 -3014
Wastewater Treatment Facility: Blue Lake
Permittee contact name:
Title:
Permittee contact phone number:
Permit Application
NPDES /SDS Permit Program
Doc Type: Permit Application
MPCA Use only
SSE
application #:
Date received:
Check number:
Facility name:
NPDES /SDS #:
City.
Fee:
❑ $310 ❑ $620 ❑ $930
Project Information
Project information packet must include the following:
Check to be sure the project information packet submitted for all projects includes all of the following items, or it will be deemed
incomplete and returned.
® Completed and properly signed Application Form. All questions must be answered and all necessary signatures included.
® Completed and executed Design Certification for Sanitary Sewer Extension Plans and Specifications.
® A location map or project site plan showing the area in which project construction will occur.
The map shall be on 8%" x 11" paper. Please list the city of project location.
® Required application fee (See below for fee calculation). Please make checks payable to: Minnesota Pollution Control
Agency (MPCA).
Please check the box corresponding to the flow increase due to this project and include the applicable application fee.
This value should correspond with the answer to question 5a.
® 0 -0.1 MGD (1 point= $310) ❑ >0.1 -1.0 MGD (2 points = $620) ❑ >1.0 MGD (3 points = $930)
The following information may be required for your project:
Check the appropriate boxes if the information is required and included with your project information packet.
❑ Plans and specifications if required by Design Certification for Sanitary Sewer Extension Plans and Specifications.
® Project is served by a Sanitary Sewer District or another city's wastewater treatment facility (W WTF).
Note: For projects connecting to a Metropolitan Council Environmental Services (MCES) facility, please
contact Anna Besse/ at 651 - 602 -1125 or for more information, go to:
hUmMovww.metrocouncil. oral environmenticustomerservice /SewerPermits, him.
Approval letter from MCES must be submitted with application to MPCA.
If above box is checked, one of the following boxes must also be checked:
❑ Authorized signature is included in signature 4 on signature page.
® Approval letter is included from Sanitary Sewer District or WWTF.
Project funding:
Will the project receive Clean Water Revolving Fund financial assistance? ❑ Yes ® No
If yes, plans and specifications must be submitted for MPCA review.
MPCA Information
For additional information and forms see the MPCA's website at htto : / /www.oca.state.mn.us /enzg9l5 or by contacting the MPCA at
651 - 296 -6300 or toll -free at 800- 657 -3864.
You can also contact the Municipal Wastewater Section staff assigned to the city the project is in. A directory of office locations can
be found at: hfti):/AAfww.oca.state.mn.us/abouttregions/index.htmi.
Send project information packet to: Fiscal Services — 6 1 floor, Minnesota Pollution Control Agency
520 Lafayette Road North, St. Paul, MN 55155
Note: 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.
www.pca.state.mn.us • 651- 296 -6300 800 - 657 -3864 TTY 651- 282 -5332 or 800- 657 -3864 • Available in alternative formats
wq- wwprm7 -15 • 712112 Page t of 8
Application Form
1. Title of project (as shown on plans and specs):
Project proposer: Lennar Corporation
Authorized representative (mayor, owner, CEO, etc.): Joe Jablonski
Project proposer address: 1630536 1h Avenue North - Suite 600
City: Plymouth State: MN Zip code: 55446 -4270
Phone: 952- 249 -3014 Fax: E -mail: joe.jablonski@lennar.com
The proposer is the entity requesting consideration for the construct of the project. The proposer is often a developer or other
private entity that is not the Permittee and will not be the ultimate owner of the sewer system. The Permittee, which is usually
the municipality, may also propose projects.
2. Project proposer's technical agent or consulting engineer: Cara Schwahn Otto
Title: Project Engineer
Name of firm or organization: Otto Associates Engineers & Land Surveyors Inc
Mailing address: 9 West Division Street
City: Buffalo State: MN Zip code: 55313
Phone: 763- 682 -4727 Fax: 763 - 682 -3522 E -mail: cara @ottoassociates.com
3. Permittee contact information
Contact name:
Title:
Phone:
4. Nature of area to be served by the proposed project
(Complete these items with respect to how many connections are being requested for the proposed project.)
a. Residential
Number of new homes that will be connected: 31
Number of existing homes not currently connected that will be connected to the sewer system:
Number of existing homes that are currently connected and will be reconnected:
b. Commercial /Industrial
(Projects are often described in different ways, so the parameters have been selected as common quantities.
Acres means the total area of the proposed project; Lots means the number of individual properties the area will be
divided into, and REU means `Residential Equivalent Unit', or unit equivalent to one home):
Commercial /Industrial that are not currently connected and will be connected:
Acres:
Lots:
REU:
Commercial /Industrial that are currently connected and will be reconnected:
Acres: Lots: REU: -
c. Other service area (describe):
5. Increased flow and Five -Day Carbonaceous Biochemical Oxygen Demand (CBOD5) loading from the proposed
project. (How much are you seeking approval for ?)
a) Flow in million gallons per day (MGD): 0.01 MGD
b) CBODS in pounds per day (Ibs /day): 18 Ibs /day
c) Flow calculation (# of units from 4 above x flow per unit): 32 x 3.3 cap /unit x 100 gal /cap /day
d) Will there be future phases or connections to the sewer system constructed for this project? ❑ Yes ® No
e) If yes, how many connections? How much flow? MGD
f) What is the total ultimate design flow capacity of the system installed with this project? 0.01 MGD
(This is the design flow for which the sewer system is designed when all future projected connections are attached.)
www.pca.state.mn.us • 651 - 296 -6300 800- 657 -3864 TTY 651- 282 -5332 or 800 - 657 -3864 • Available in alternative formats
wq- wwprm7 -15 • 712112 Page 2 of 8
6. Specification of the WWTF where flow will be treated (Contact the WWTF for current specifications.)
a) Where will the wastewater be treated? (Give the specific name of the WWTF) Blue Lake
b) Design Average Wet Weather flow (AW W) (use design average flow if AWW not available): MGD
c) Actual current annual average daily flow received in the past 12 months: MGD
d) Actual current annual average daily CBOD5 loading in the past 12 months: milligrams per liter (mg /L)
e) Estimate the total number of new connections anticipated, including other projects, in the next
12 months. (Municipalities in sewer districts need only estimate the number for your municipality.) Connections
f) Do the downstream collection facilities and WWTF have sufficient capacity to treat current flow and the flow from this
and other approved connections not yet constructed? ❑ Yes ❑ No
If no, explain:
7. Bypasses /Overflows in the collection and treatment facilities (This includes overflows from municipalities that may
manage only collection systems. Provide additional pages as needed to explain.)
a) Have there been any overflows, back -ups, releases or other discharges of wastewater from the collection system,
including interceptor sewers, downstream of this project in the past 12- months? ❑ Yes ❑ No
If yes, describe:
b) Have there been any bypasses, overflows, releases or other discharges of partially treated wastewater at the WWTF in
the past 12- months? ❑ Yes ❑ No
If yes, describe:
c) If yes to a) or b), what steps are being taken to address those events?
8. Determination for the need of an Environmental Assessment Worksheet (EAW)
Does any part of the system proposed with this project have a total ultimate average design flow greater than 1 MGD?
❑ Yes ® No
Minn. R. 4410.4300, subp. 18, A. For expansion, modification, or replacement of a municipal sewage collection system
resulting in an increase in design average daily flow of any part of that system by 1,000,000 gallons per day or more if the
discharge is to a wastewater treatment facility with a capacity less than 20,000,000 gallons per day or for expansion,
modification, or replacement of a municipal sewage collection system resulting in an increase in design average daily flow of
any part of that system by 2, 000, 000 gallons per day or more if the discharge is to a wastewater treatment facility with the
capacity of 20,000,000 gallons or greater, the MPCA shall be the Responsible Government Unit (RGU).
(Even if there are no connections proposed as part of this project an EAW must be completed prior to issuance of a permit.)
Has the project been reviewed in a previous Environmental Assessment Worksheet (EAW)? ❑ Yes ® No
If yes, note the name of the project reviewed in the EAW, the RGU, and the date of the negative declaration:
Name of the project reviewed in EAW:
Responsible Governmental Unit:
Date of the negative declaration:
9. Administrative table (Complete the following table to be used for administrative purposes.) Note: If completing form
electronically, this section will fill in automatically based on above entries.
Permittee: City of Chanhassen
Project title: Boulder Cove
Flow increase MGD (from 5a): 0.01 MGD BOD5 increase Ibs /day (from 5b): 18
Number of new homes connected (from 4a): 31
Number of existing homes not connected that will be connected (from 4a): 1
Commercial /Industrial that are not currently connected and will be connected (from 4b):
Acres: Lots: REU:
Other service area description (from 4c):
www.pca.state.mn.us • 651- 296 -6300 • 800- 657 -3864 TTY 651- 282 -5332 or 800 -657 -3864 • Available in alternative formats
wq- wwprm7 -15 • 712112 Page 3 of 8
Certification and Signature
Federal Regulations (40 CFR Part 122.22) and State Regulations (Minn. Rule 7001.0060) require all permit applications to be
signed as follows:
A. For a corporation: by a responsible corporate officer. For the purpose of this permit, a responsible corporate officer means:
1.) a president, secretary, treasurer or vice president of the corporation in charge of a principal business function, or any
other person who performs similar policy or decision - making functions for the corporation; or 2.) The manager of one or
more manufacturing, production or operating facilities employing more than 250 persons or having a gross annual sales or
expenditures exceeding 425 million, if authority to sign documents has been assigned or delegated to the manager in
accordance with corporate procedures.
B. For a partnership or sole proprietorship: by a general partner or the proprietor, respectively.
C. For a municipality, county or other political subdivision: by a principal executive officer or ranking elected official.
D. For a state, federal or other public agency /agents: by a commissioner, assistant or deputy commissioner; director,
assistant or deputy director.
1. Project Proposer's Signature
"I certify under penalty of law that this document and all attachments were prepared under my direction orsupervision in accordance
with a system designed to assure that qualified personnel property gather and evaluate the information submitted. Based on my
inquiry of the person orpersons 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. 1 am aware that there are significant
penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations."
Name (print): Title:
Authorized signature: Date:
2. Design Engineer's Certification and Signature
"I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance
with a system designed to assure that qualified personnel property gather and evaluate 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, including the possibility of fine and imprisonment for knowing violations."
Name (print): Cara Scchiwahn Otto Title: PE
Authorized signature: l / -AL 48 Date: 05 -09 -14 PE Registration No. 40433
3. Permittee's Approval
"My signature, or the signature of a delegated official, represents the approval of this project's connection to the sewer system
and/or wastewater treatment facility under my jurisdiction. I am aware that there are significant penalties for submitting false
information, including the possibility of fine and imprisonment."
Name (print): Title:
Authorized signature: Date:
4. Sanitary District or WWTF Approval - Authorized Municipal Official Signature (or delegated authority) from
Sanitary Sewer District or Municipality, if different than Permittee.
"My signature, or the signature of a delegated official, represents the approval of this project's connection to the sewer system
and/or wastewater treatment facility under my jurisdiction. I am aware that there are significant penalties for submitting false
information, including the possibility of fine and imprisonment."
If the Sanitary Sewer District or Regional treatment authority has provided project approval under a separate process,
a copy of that approval letter may be submitted with this application in place of this signature.
Name (print): Title:
Authorized signature: Date:
www.pca.state.mn.us • 651- 296 -6300 800- 657 -3864 TTY 651- 282 -5332 or 800 -657 -3864 • Available in alternative formats
wq- wwprm7 -15 • 712112 Page 4 of 8
Design Certification for Sanitary Sewer Extension Plans and Specifications
Title of plans and specifications: Boulder Cove
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 Standards for 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
a. Answer questions No. 1 -52 below.
b. If both questions No. 29 and 52 are answered Yes:
1. Sign the Fast Track Certification Statement if applicable.
2. 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)
a. Answer questions No. 1 -52 below.
b. If either question No. 29 or 52 are answered No:
1. Do not sign the Fast Track Certification statement.
2. Sign the Statement for Detailed Review.
3. Provide justification for not following the specified recommendations.
4. Submit plans and specifications for review and approval.
1. What is the per capita or per unit per day design flow? 100 gal /cap /day
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 capita flow
to the treatment facility?
3. What is the design peaking factor?
Sewer Pipe:
Yes No N/A
® ❑ 4. Are all sewers designed without an overflow or bypass point?
® ❑ ❑ 5. Are all gravity sewers at least 8 inches in diameter? (Answer N/A only if there are no gravity sewers.)
• ❑ 6. Are all sewers sufficiently deep to receive wastewater from basements and to prevent freezing, or is
insulation provided for sewers that are not placed at a depth to prevent freezing?
• ❑ 7. Is all nonconductive sewer pipe designed to be installed with a locate wire or equally effective means of
marking the location in accordance with Minn. R. 7560.0150?
Additional information for this rule can be obtained from the Minnesota Office of Pipeline Safety website
at hfto://www.dps.state.mn.us/i)ipeline/index.htmi or by calling 651 - 296 -9636.
8. How will pipe be marked for location? GPS locating and record drawings
❑ ❑ ® 9. if there are sewers that cross or enter any water body, has the Minnesota Department of Natural
Resources (DNR) been contacted to determine if the project will require a permit for construction?
(Answer N/A only if there are no sewers located in a water body.)
www.pca.state.mn.us 651 - 296 -6300 800- 657 -3864 TTY 651- 282 -5332 or 800- 657 -3864 • Available in alternative formats
wq- wwprm7 -15 • 712112 Page 5 of 8
Sewer Pipe (continued):
Yes No NIA
❑ ❑ ® 10. If the project has the potential to adversely impact wetlands, has a permit or approval from another
official statewide program (U.S. Army Corps of Engineers, DNR, or Minnesota Wetlands Conservation
Act) been issued to specifically address the project? (Answer N/A only if there are no impacts to
wetlands.)
11. Name of program and permit number:
❑ ❑ ® 12. If the project has the potential to adversely impact wetlands and a permit or approval from another
official statewide program is not require, has the mitigation sequence according to Minn. R. 7050.0186,
subp. 2, been followed? (Answer N/A only if there are no impacts to wetlands or a permit as described
in #10 is required.)
Check the box corresponding to the steps in the sequence followed:
❑1, avoid the impact altogether
02. minimize the impact by limiting the degree or magnitude of the actions and by taking affirmative
actions to rectify the impact and reduce or eliminate the impact over time
❑3. mitigate the unavoidable impacts by compensation according to the rule.
❑ ❑ ® 13. 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 operation? (Answer N/A only if there are no pressure sewers.)
❑ ❑ ® 14. Is there an air relief or vacuum relief valve provided at all high points in force mains? (Answer N/A only if
there are no pressure sewers.)
❑ ❑ ® 15. Are grinder pumps or other solids removal equipment included for any force main that is less than 4
inches in diameter? (Answer N/A only if there is no pressure sewer or force main less than 4 inches.)
® ❑ 16.
Are all sewers designed with mean velocities when flowing full, of at least 2.0 feet per second, based on
Manning's formula using an "n" value of 0.013?
® ❑, ❑ 17.
Is the slope of 8 -inch diameter gravity sewer at least 0.40 percent; 10 -inch diameter sewer at least 0.28
percent; 12 -inch diameter sewer at least 0.22 percent; 14 -inch diameter sewer at least 0.17 percent; 15-
inch diameter sewer at least 0.15 percent; 16 -inch diameter sewer at least 0.14 percent; and 18 -inch
diameter sewer at least 0.12 percent? 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. If proposed slopes are less than those listed above, what is the depth of flow and velocity of flow at
the average wet weather flow and peak hourly wet weather flow (PHW W) for affected pipe sections?
AWW flow (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 must be cleaned
at least once per year to ensure problems to not develop and to develop a site specific maintenance
interval. (Answer N/A only if no gravity sewer)
® ❑ 18.
Are individual service connections to the sewer designed to be water tight and do not protrude into the sewer?
❑ ® 19.
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?
If these separation distances cannot be obtained, an approval from the Minnesota Department of Health
(MDH) and /or the Department of Labor and Industry (131-1) shall be included with this application.
® ❑ ❑ 20.
Has an application for water supply and /or building sewer construction been submitted to the MDH or
DLI? (Answer N/A only if there is no water supply piping included with this project.)
Any project that involves the construction of water supply pipes may also require a permit from the MDH
or the DLI. For additional information refer to the MDH website at
hftp' /ANww.health.state.mn.us/divs/eh/water/index.html or the DLI website at
hfti)' /twww.dii.mn.gov/CCLD/Plumbing.asp.
® ❑ 21.
Has an inventory of all wells on all properties in the project area been completed, and will all wells be at
least 50 feet from buried sewers, lift stations and grinder stations, as required by Minn. R. ch. 4725
(Minnesota Well Code)?
For more information on well setbacks and exceptions to the 50 -foot requirement, refer to the MDH
website at htto /hvww.health.state.mn.us/divs/eh/wells/index.htmI or contact the MDH Well Management
Section at 651 - 201 -4600 or 1- 800 - 383 -9808.
www.pca.state.mn.us •
651 - 296 -6300 • 800- 657 -3864 TTY 651 - 282 -5332 or 800- 657 -3864 • Available in alternative formats
wq- wwprm7 -15 • 712112
Page 6 of 8
Sewer Pipe (continued):
Yes No NIA
• ❑ ❑ 22. Are all manholes at least 48 inches in diameter? (Answer N/A only if there are no manholes.)
• ❑ ❑ 23. Are all manholes constructed to prevent surface water runoff from entering through the cover? (Answer
❑
❑
®
24.
®
❑
❑
25.
®
❑
Will the lift station be fully operational and accessible during a 25 -year flood?
26.
❑
❑
®
27.
®
❑
28.
❑
®
Where high ground water conditions are anticipated, has the buoyancy of the lift station structure been
29.
N/A only if there are no manholes.)
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 N/A 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 operation
and maintenance personnel have access to adequate cleaning equipment that can accommodate the
spacing? (Answer N/A only if all pressure sewer.)
Will a leakage test be performed to demonstrate watertightness of the sewer pipes?
What test method will be used? Air test
Will a deflection test be performed on all plastic gravity sewer after the pipe has been in place for at least
30 days? (Answer N/A only if televising or other method is used instead.)
Will sewer line televising be performed? (Answer only as Yes or N /A.)
Have questions #4 through #28 been answered as Yes or N /A?
Yes
No
N/A
❑
®
Does the project include any work on a lift station? (If No, go to question No. 52 and answer Yes.)
❑
❑
30.
Will the lift station be fully operational and accessible during a 25 -year flood?
❑
❑
31.
Will the lift station structural, electrical and mechanical equipment be protected from physical damage
during at 100 -year flood?
❑
❑
❑ 32.
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 N/A only if high ground
water conditions are not anticipated.)
❑
❑
❑ 33.
Are wet wells and dry wells completely separated and common walls are gas tight? (Answer N/A only if
no dry well is included)
❑
❑
34-
Are multiple pumps provided such that with any unit out of service, the remaining units have capacity to
handle the design peak hourly wet weather flow?
❑
❑
35.
Are all pumps capable of passing spheres of at 3 inches in diameter?
❑
❑
36.
Are all pump suction and discharge openings at least 4 inches in diameter?
❑
❑
37.
Are all electrical components in raw wastewater wet wells in compliance with National Electrical Code
requirements for Class I Group D, Division 1 locations?
❑
❑
38.
There are no bypass or overflow pipes from the wet well?
❑
❑
39.
Are suitable shutoff and check valves placed on the discharge line of each pump?
❑
❑
40.
Are check valves located between the shutoff valve and the pump?
❑
❑
41.
Are check valves placed in the horizontal position, except ball valves which may be placed vertically?
❑
❑
42.
Are shutoff and check valves for submersible pump lift stations located in a separate valve pit? If a
separate valve pit is not provided, are all valves easily accessible for maintenance?
❑
❑
❑ 43.
If a drain line is provided between a valve pit or dry well and a wet well, is the drain line equipped with a
gas and water tight valve or extended below the low water level in the wet well to prevent entry of
hazardous cases to the valve pit? (Answer N/A only if a drain line is not included.)
❑
❑
❑ 44.
If continuous wet well ventilation is provided, are at least 12 complete air changes per hour provides?
(Answer N/A only if submersible pump lift station.)
❑
❑
❑ 45.
If intermittent wet well ventilation is provided, are at least 30 complete air changes per hour provided?
(Answer N/A only if submersible pump lift station.)
❑
❑
❑ 46.
If continuous dry well ventilation is provided, are at least 6 complete air changes per hour provided?
(Answer N/A only if submersible pump lift station.)
www.pca.state.mn.us •
651- 296 -6300 800- 657 -3864 TTY 651- 282 -5332 or 800- 657 -3864 • Available in alternative formats
wq- wwprm7 -15
• 712112
Page 7 of
Lift Stations (continued):
Yes
No NIA
❑
❑ ❑
47.
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 N/A only if submersible
pump lift station.)
❑
❑
48.
Are provisions for flow measurement provided? Type:
❑
❑
49.
Are a sufficient number of running time meters provided to record when each pump is running and when
multiple pumps are running at the same time?
❑
❑
50.
Is an appropriate alarm system provided to indicate power failure, pump failure, unauthorized entry, or
other malfunction? Type of alarm:
❑
❑
51.
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 pumping
equipment? Type:
®
❑
52.
Have questions No. 30 through No. 52 been answered as Yes or N /A?
Fast Track Certification Statement (Do not submit plans and specifications)
"I have answered Checklist items No. 29 and No. 52 above as Yes or N/A 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 information, 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: l A A
Date: 05 -09 -14
Typed or printed name: Cara Schwahn Otto
Registration Number: 40433
Address: 9 West Division Street Phone Number: 763 -682 -4727
City: Buffalo State: MN Zip code: 55313
Statement for Detailed Review (Plans and specifications must be submitted)
"I have answered No to Checklist item No. 29 or No. 52 because the design does not conform with all of requirements in the above
listed standards, specifications, and guidelines."
Name (print):
Signature:
Date:
List of standards, specifications, and guideline not complied with (attach additional pages if needed):
Section
for variation
www.pca.state.mn.us • 651- 296 -6300 800- 657 -3864 TTY 651- 282 -5332 or 800- 657 -3864 • Available in alternative formats
wq- wwprm7 -15 • 712112 Page 8 of 8