HomeMy WebLinkAboutNotice of Intent Water Extension 12-19-18T : NOTICE OF INTENT TO CONSTRUCT A WATER MAIN EXTENSION
State Form 49008 (R314-15)
Approved by State Board of Accounts, 2015
General Construction Permit For
1. Title of proposed project
•
2. County of proposed project
Jackson's Grant on Williams Creek, Section 6
Hamilton
3. Location of proposed project (including nearest public intersection and nearest quarter Section, Township, Range)
West side of Spring Mill Road approximately 4,000' North of 116th Street.
4. Name, title, e-mail address and firm of responsible person (as defined in 327 1A 8-3.5-6)
5. Telephone number of responsible person
Douglas B. Wagner, Senior Vice President, dwagner@republicdev.com Jackson's Grant Real Estate
( 317) 770-1818
Company, LLC by JG Development Company, LLC its manager
6. Address of responsible person (number and street, city, state, and ZIP code)
13578 East 131 st Street, Suite 200, Fishers, Indiana 46037
7. Name of Public Water System (PWS)
Carmel City Utilities
8. PWS identification number
5229004
9. Address of PWS (number and street, city, state, and ZIP code)
10. Telephone number of PWS
30 West Main Street, Suite 220, Carmel, Indiana 46032
( 317) 571-2451
11. Name and firm of professional engineer 12. Telephone number of professional engineer
David J. Stoeppelwerth - Stoeppelwerth & Associates, Inc. 1 ( 317) 570-4763
13. Address (number and street, city, state, and ZIP code) and e-mail address of professional engineer
7965 East 106th Street, Fishers, Indiana 46038 - brobinson@stoeppelwerth.com
14. Name and e-mail address of developer (If applicable)
Douglas B. Wagner dwagner@republicdev.com
15. Telephone number of developer
( 317 ) 770-1818
16. Address of developer (number and street, city, state, and ZIP code)
13578 East 131 st Street, Suite 200, Fishers, Indiana 46037
17. Timing of construction (check one of the following):
HThe proposed construction of the water main will begin on March 2019 and be completed on March 2020(Cannot begin construction less than thirty (30)
days after IDEM receives a complete and sufficient NOI.)
❑ The proposed construction schedule will be submitted separate from this NOI at least ten (10) working days before the commencement of the construction
and will include a copy of the information on the first page of this NOI. (Cannot begin construction less than thirty (30) days after IDEM receives a
complete and sufficient NOL.
18. Fee Schedule: The complete NOI form may be submitted by e-mail (dvmoi@idem.in.gov) or by certified mail to the
❑ No fee, exempted under 327 IAC 8-3-7(a). address below.
pp No fee for water main extensions under 2,500 linear feet. Indiana Department of Environmental Management
❑ $150 for water main extensions from 2,501 to 5,000 linear feet. Drinking Water Permits Section (IGCN Rm 1201)
100 North Senate Avenue
❑ $250 for water main extensions from 5001 to 10,000 linear feet. Indianapolis, IN 46204
❑ $500 for water main extensions greater than 10,000 linear feet. ffa fee is required, see instructions forpayment options.
19. Certifications:
Responsible Person:
"I certify that I have reviewed and understand the applicability and eligibility requirements of this rule and that the water main proposed with the submission of
this NOI meets the applicability and eligibility requirements of this rule. I also certify that the design and construction of this project will be performed under my
direction or supervision to assure conformance with 327 IAC 8-3.5 and will meet all local rules or laws, regulations and ordinances. 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 f fine and imprisonment.
Sign,ptOre of responsible rson
Date signed (month, day, year)
a"
December 19, 2018
Professional Engineer:
"I certify under the penalty of law that the design of this project will be performed under my direction or supervision to assure conformance with 327 IAC 8-
3.5 and that the plans and specification will require the construction of said project to be in
performed conformance with this rule. The design of the
proposed project will meet all local rules or law, regulations and ordinances. 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."
=aturerof sio a ineerDate
signed (month, day, year)
December 19, 2018
Page 1 of 2
Developer:
"I certify under the penalty of law that the construction of this project will be performed under my direction or supervision to assure conformance with 327 IAC
8-3.5. The construction of proposed project will meet all local rules or laws, regulations and ordinances. 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."
Signature of devZloer
Date signed (month, day, year)
December 19, 2018
PWS Representative:
"I certify under the penalty of law that I have agreed to furnish water to the area in which the water main is proposed. I acknowledge the public water system's
responsibility for examining the plans and specifications to determine that the proposed water main meet local rules or laws and ordinances.
I also acknowledge the public water system's responsibilities as outlined in 327 IAC 8-3.5-12. 1 am aware that there are significant penalties for submitting false
information, including the possibility of fine and imprisonment."
Signature of PWS representative
Date signed (month, day, year)
Project Design Criteria:
Alternative Technical Standards (327 IAC 8-3.2-20)
20. Are any "Alternative Technical Standards" proposed to be used in this project?
❑ Yes, I have attached copies of the approval with the N01. ❑ No
Public Water System Capacity Status
21. The PWS's Daily Production Firm Capacity: A. MGD B. GPM
22. The PWS's five (5) highest demand days in the previous two (2) years only:
Demand (MGD)
Date (month, day, year)
1.
2.
3.
4.
5.
23. Average of five (5) Peak Daily Demand (PDD) listed above:
C. MGD
24. Ratio of PDD to PWS Daily Production Capacity = (Item D = Item C / Item A x 100)
D. %
25. Anticipated Customer Demand of Proposed Water Main
Residential Customers:
E. Number of homes
12
F. Average Daily Demand times Peaking Factor (at least 0.87
gpm/home) 0,87
G. TotalAverage Daily Demand times Peaking Factor (G = E x F)
10.44
gpm
Other (Commercial and Industriao Customers:
Description (including size of domestic meter):
Average Daily Demand (the 'Safe MaximumOperating Capaci)l" of domestic meter)
gpm
gpm
Sub Total:
H. gpm
Total Customer Demand of Proposed Water Main (gpm) = (Item G + item H)
1. 10.44 gpm
Ratio of total Customer Demand of Proposed Water Main (gpm) to the PWS Daily Production Firm
Capacity (gpm) (Item J = Item I/ Item B x 100)
J. %
26. Cross Connection Hazard Prevention
A. Are any of the new customers included in Section 25 designated as cross connection hazards (see instructions)?
❑ Yes No ❑ N/A
B. Will an air gap be constructed or a reduced pressure principal backflow preventer be installed on the customer's service line?
❑ Yes ❑■ No ❑ N/A
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