HomeMy WebLinkAboutSanitarySewerConstructionPermit_12-18-19Instructions for State Form 53159, Application for Sanitary Sewer Construction Permit
All of the following necessary items must be submitted or the construction permit application will be
deemed incomplete and will not be reviewed. Only one copy of each necessary item needs to be
submitted.
1. Application for Sanitary Sewer Construction Permit
• Applications from municipalities must be signed and dated by an authorized official and
applications from non -municipalities must be signed and dated by the owner or a
representative.
2. Collection System Design Summary
3. Capacity Certification from the collection and treatment system owner(s) to which the
proposed sanitary sewer and/or force main will be connected
• If more than one utility will be transporting and/or treating the wastewater, a Capacity
Certification from each utility is required.
4. Registered Professional Engineer or Land Surveyor Certification by the applicant's engineer
or land surveyor
5. Final Construction Plans and Specifications
• Every page of the plans as well as the cover page for any specifications should be signed,
sealed, and dated by an Indiana registered professional engineer or land surveyor. Land
surveyors may certify plans and specifications for gravity type sanitary sewers only, not
including lift stations and force mains.
6. Identification of Potentially Affected Persons form and mailing labels
If the completed application does not satisfy all administrative and technical requirements, a
deficiency notice will be sent. If all deficiencies are not adequately addressed within sixty (60) days
from the date of the deficiency notice, the permit application will be denied.
A copy of this application can be found at: www.in.gov/idem/cleanwater/2430.htm
Send construction permit applications to:
Indiana Department of Environmental Management
Office of Water Quality
Facilities Construction Section, Mail Code 65-42FC
100 North Senate Avenue, Room N1255
Indianapolis, IN 46204-2251
For any questions, call the Facility Construction Section at 317/232-5579.
APPLICATION FOR SANITARY SEWER
Indiana Department of Environmental Management
CONSTRUCTION PERMIT PER 327 IAC 3
0State
Office of Water Quality
Facilities Construction Section, Mail Code 65-42FC
Form 53159 (R5111-19)
100 North Senate Avenue, Room N1255
Indianapolis, IN 46204-2251
Name R Mr. or ❑ Ms.
Name R Mr. or ❑ Ms.
Douglas B. Wagner
David J. Stoeppelwerth
Name of Organization
Name of Company
Jackson's Grant Real Estate, Co., LLC by JIG Development Company, LLC its manager
Stoeppelwerth & Associates, Inc.
Address (number and street, city, state, and ZIP)
Address (number and street, city, state, and ZIP)
13578 East 131 st Street, Suite 200
7965 East 106th Street
Fishers, Indiana 46037
Fishers, Indiana 46038
Telephone Number
Telephone Number
(317 ) 770-7011
(317 ) 849-5935
E-Mail Address
E-Mail Address
dwagner@republicdev.com
brobinson@stoeppelwerth.com
Name Describe the scope and/or purpose of this project
Jackson's Grant on Williams Creek, Section 7
A proposed Section 7 of the Jackson's Grant on
Location or Project Boundaries Williams Creek subdivision which will consist of
West side of Spring Mill Road approximately 17 singe -family lots.
6,400' North of 116th Street.
City or Town
Carmel
County
Hamilton
SOURCE • F FUNDING
❑ IFA's Wastewater State Revolving Fund Loan Program ❑ Local Funds
❑ OCRA's Community Development Block Grant ❑■ Private Funds
❑ USDA's Rural Development Loan and Grant Assistance ❑ Other:
CERTIFICATION• SIGNATURE
I swear or affirm, under penalty of perjury as specified by IC 35-44.1-2-1 and other penalties specified by IC
13-30-10 and IC 13-15-7-1(3), that the statements and representations in this application are true, accurate,
and complete.
Printed Name of Person Signing
Douglas B. Wagner
Title
Douglas B. Wagner, Senior Vice President, Jackson's Grant Real Estate Company, LLC by JG Development Company, LLC its manager
��gnure
Date Signed (month/day/year)
Decerriber 18(2019
(Please refer to IC 13-30-10 for penalties of submission of false information.)
Page 1 of 6
Part of State Form 53159 (R5
COLLECTION
Design • to 327 3.6-11 •DesignFlow Rate Requirements
Description of Units Served Design Flow Per Unit Number of Units
Unit Design Flow
Example: Single family homes
310 gpd/unit
30
9,300 gpd
17 Single -Family Homes
310 (gpd/unit)
17
5,270 gpd
(gpd/unit)
gpd
(gpd/unit)
gpd
(gpd/unit)
gpd
(gpd/unit)
gpd
Average Design Flow
5,270 gpd
Peaking factor
4.o
Peak Design flow
21,080 gpd
❑ Applicable ❑ Not Applicable
Length
Diameter
Material
ASTM or AWWA
Standard
SDR or
DR
Pressure
Class (psi)
Installation
Method
Example:
1,525 ft
8-Inch
PVC
ASTM D3034
SDR-35
N/A
Open Cut
ft
in
ft
in
ft
in
ft
in
ft
in
-
❑ Applicable ❑ Not Applicable
Length
Diameter
Material
ASTM or AWWA
Standard
SDR or
DR
Pressure
Class (psi)
Installation
Method
Example:
1,525 ft
8-inch
PVC
ASTM D2241
SDR-21
200 psi
Open Cut
ft
in
ft
in
ft
in
ft
in
ft
in
Inspection during construction will be provided by
Clay Township Regional Waste District
Maintenance after completion will be provided by
Clay Township Regional Waste District
Wastewater treatment will be provided by
Clay Township Regional Waste District
❑ Applicable ❑■ Not Applicable
1. Location:
2. Type of pump (example: submersible, dry pit):
3. Number of pumps:
4. Constant or variable speed:
5. Design pump rate (gpm) and TDH (ft):
6. Operating volume of the wet well (gal):
Page 2 of 6
Part of State Form 53159 (R5 / 11 19)
7.
Average detention time in the wet well (min):
8.
Type of standby power/pump provisions:
9.
Type of alarm:
10.
Additional information:
•
❑ Applicable Not Applicable
1.
Number of stations: simplex duplex triplex
2.
Number of residential connections per simplex station (two maximum):
3.
Design pump rate (gpm) at maximum TDH (ft):
4.
Type of alarm:
5.
Privately or utility owned and maintained:
6.
Additional information:
❑ Applicable ❑■ Not Applicable
1.
Location:
2.
Total volume of vacuum tank (gal):
3.
Operating volume of the vacuum tank (gal):
4.
Number and size (HP) of vacuum pumps:
5.
Number and type of sewage pumps:
6.
Constant or variable speed:
7.
Design pump rate (gpm) and TDH (ft):
8.
Type of standby power/pump provisions:
9.
Type of alarm:
10.
Additional information:
Certification Seal, Signature, and Date
Printed Name of Engineer or Land Surveyor
David J. Stoeppelwerth
Signature
,C,W
Date Signed (month/day/year)
Decermber 18/ 2019
V
C>
9358
-t� % STATE OF
Ar��irl pONAL
A factor of four (4) is prescribed by 327 IAC 3-6-11. However, an alternative
peaking factor may be justified by other means (327 IAC 3-6-32) or as provided
by Ten State Standards 11.243: Peaking Factor = (18 + SIP) / (4 + �P), where P
= population in thousands.
Provide pump and system curves and design calculations for TDH. If connecting
to an existing force main, provide upstream lift station pump curves and describe
how the proposed flow will affect the lift station performance during
simultaneous operation.
For small diameter low-pressure sanitary sewer systems, provide a spreadsheet
that includes the maximum expected simultaneous operation of the proposed
grinder pumps, maximum expected flow (gpm) and fluid velocity (ft/sec), static
head and accumulated friction loss, and expected accumulated total dynamic
head (TDH).
The average detention time in the wet well (cycle time between pump on/off settings) should be between 5 and 30
minutes. The cycle time may be calculated from the following equation: Cycle Time = (V / (D - Q)) + (V / Q), where D =
discharge flow rate out of the wet well (design pump rate) in gpm, Q = inflow rate into wet well (average design flow) in
gpm, and V = operating volume of wet well (between pump on/off settings) in gallons.
Page 3 of 6
Part of State Form 53159 (R51 11 .19)
CAPACITY CERTIFICATION
This form must be filled -out in its entirety with no alterations.
Name of Applicant: Jackson's Grant Real Estate Co., LLC by JG Development Co., LLC its manager
Name of Applicant Representative: Douglas B. Wagner
Name of Project: Jackson's Grant on Williams Creek, Section 7
CERTIFICATION
, representing the
(Name of individual)
(Name of municipality or utility)
have the authority to act on behalf of the
(Title)
, in my capacity as
(Name of municipality or utility)
certify that I have reviewed and understand the requirements of 327 IAC 3 and that the sanitary
collection system proposed, with the submission of this application, plans and specifications, meets
all requirements of 327 IAC 3. 1 certify that the daily flow generated in the area that will be collected
by the project system will not cause overflowing or bypassing in the collection system other than
NPDES authorized discharge points and that there is sufficient capacity in the receiving water
pollution treatment/control facility to treat the additional daily flow and remain in compliance with
applicable NPDES permit effluent limitations. I certify that the proposed average flow will not result in
hydraulic or organic overload. I certify that the proposed collection system does not include new
combined sewers or a combined sewer extension to existing combined sewers. I certify that the
ability for this collection system to comply with 327 IAC 3 is not contingent on water pollution/control
facility construction that has not been completed and put into operation. I certify that the project
meets all local rules or laws, regulations and ordinances. The information submitted is true, accurate,
and complete, to the best of my knowledge and belief. I am aware that there are significant penalties
for submitting false information, including the possibility of fine and imprisonment.
Peak Design Flow (gallons per day)
21,080
Owner of Receiving Collection System
Clay Township Regional Waste District
Name of Wastewater Treatment Plant
Clay Township Regional Waste District
Mailing Address of Certifying Representative
(number and street, city, state, and ZIP code)
E-mail Address of Certifying Representative
I am certifying for the ❑ Collection System ❑ Treatment Facility
Signature
Date Signed (month/day/year)
(Please refer to IC 13-30-10 for penalties of submission of false information.)
Page 4 of 6
Part of State Form 53159 (R5 / 11--19)
CERTIFICATION OF REGISTERED PROFESSIONAL ENGINEER OR LAND SURVEYOR
This form must be filled -out in its entirety with no alterations.
Name of Applicant: Jackson's Grant Real Estate Co., LLC by JG Development Co., LLC its manager
Name of Applicant Representative: Douglas B. Wagner
Name of Project: Jackson's Grant on Williams Creek, Section 7
David J. Stoeppelwerth
CERTIFICATION
, representing the project applicant, in my capacity as a
(Name of Individual)
registered professional Engineer 19358
(Engineer or Land Surveyor) (Indiana registration number)
certify the following under penalty of law: The design of this project has been performed under my
direction or supervision to assure conformance with 327 IAC 3 and the plans and specifications
require the construction of said project to be performed in conformance with 327 IAC 3-6. The peak
daily flow rates, in accordance with 327 IAC 3-6-11 generated from within the specific area that will
be collected by the proposed collection system that is the subject of the application, plans, and
specifications (when functioning as designed and properly installed), will not cause overflowing or
bypassing in the same specific area serviced by the proposed collection system other than from
NPDES authorized discharge points. The proposed collection system does not include new
combined sewers (serving new areas) or a combined sewer extension to existing combined sewers.
The sewer at the point of connection is physically in existence and operational. Based upon
information provided by the owner of the Wastewater System, the ability for this collection system to
comply with 327 IAC 3 is not contingent on downstream water pollution/control facility construction
that has not been completed and put into operation. The design of the proposed project meets
applicable local rules or laws, regulations and ordinances. The information submitted is true,
accurate, and complete, to the best of my knowledge and belief. I am aware that there are significant
penalties for submitting false information, including the possibility of fine and imprisonment.
Average Design Flow (gallons per day)
5,270
Peak Design Flow (gallons per day)
21,080
Owner of Receiving Collection System
Clay Township Regional Waste District
Name of Wastewater Treatment Plant
Clay Township Regional Waste District
Signature
Date Siggned (month/day/year)
Decenper 18,/2019
(Please refer to IC 13-30-10 for penalties of submission of false information.)
Page 5 of 6
ate'-,rt of ``= aC ' Form 53159 (R5 / 11-19)
IDENTIFICATION OF POTENTIALLY AFFECTED PERSONS
Please list any and all persons whom you have reason to believe have a substantial or proprietary
interest in this matter, or could otherwise be considered to be potentially affected under law. Failure
to notify a person who is later determined to be potentially affected could result in voiding IDEM's
decision on procedural grounds. To ensure conformance with Administrative Orders and Procedures
Act (AOPA) and to avoid reversal of a decision, please list all such parties. The letter on the opposite
side of this form will further explain the requirements under the AOPA. Attach additional names and
addresses on a separate sheet of paper, as needed.
Name
Address (number and street)
City
State ZIP Code
CERTIFICATION
I certify that to the best of my knowledge I have listed all potentially affected parties, as defined by IC
4-21.5-3-5.
City
Name
Please see attached.
Address (number and street)
State ZIP Code
Name
Address (number and street)
City
State ZIP Code
Name
Address (number and street)
city
State ZIP Code
Name
Name
Address (number and street)
City
State ZIP Code
Name
Address (number and street)
city
State ZIP Code
Name
Name
Address (number and street)
city
State ZIP Code
Name
Name
Address (number and street)
City
State
ZIP Code
Name
Address (number and street)
City
State ZIP Code
Proposed Facility Name City
Jackson's Grant on Williams Creek, Section 7 Carmel
Printed Name of Person Signing County
David J. Stoeppelwerth Hamilton
Signature�,,.��.,�Z Date Signed (month/day/year)
Page 6 of 6
Proposed Facility Name City
Jackson's Grant on Williams Creek, Section 7 Carmel
Printed Name of Person Signing County
David J. Stoeppelwerth Hamilton
Signature�,,.��.,�Z Date Signed (month/day/year)
Page 6 of 6
Page 6 of 6
Identification of Potentially Affected Persons Instructions
The Administrative Orders and Procedures Act (AOPA), IC 4-21.5-3-5, requires that the Indiana
Department of Environmental Management (IDEM) give notice of its decision on your application to
the following persons:
• Each person to whom the decision is specifically directed
• Each person to whom a law requires notice be given
The following are the minimum recommendations made as to who should be included in this list:
• All adjoining landowners to the property where the proposed construction is to occur
• All persons or entities with a substantial and direct proprietary interest in the issuance of this
permit
• Anyone who is known to have expressed concern or an interest in this particular project or
projects in this specific area
• Anyone else whom the applicant may feel that might be potentially affected by the issuance of
this permit
IC 13-15-3-1 requires IDEM to provide notice of receipt of a permit application to the following:
• The county executive of a county affected by a permit application
• The executive of a city affected by a permit application
• The executive of a town council of a town affected by a permit application
Under IC 13-15-3-1 (b) IDEM is requesting information necessary to provide such notice to the
appropriate officials.
Mailing labels are required to be submitted with your project. These mailing labels need to have the
names and addresses of the affected parties along with our mailing code (which is 65-42FC) listed
above each affected party listing.
For Example: 65-42FC
JOHN DEERE
111 CIRCLE DR
YOUR CITY IN 44444