A letter from the owner or owner’s agent or other ownership group for a privately owned sewage collection system must be submitted and state that they will be financially responsible for the operation, maintenance and repair of this privately owned sewage collection system which ends at the property line. If an ownership group exists, then Declaration of Covenants, Conditions, and Restrictions (CC&R’s) are required. Also include in the letter the following information such as project address, parcel number, and legal description in addition to the Project Number and Plan Check Number. The letter should be written on the owner’s or owner’s delegate company letterhead and signed and dated by the owner or owner’s delegate. The letter must be signed in blue ink to indicate original copy. For additional information, please see the attached of Aquifer Protection Program General Permit Plan Review and Special inspection Procedures for Privately Owned Sewage Collection Systems and Private Sewer Construction Authorization. Please address and send the letter to the following: City of Phoenix Planning and Development Department 200 West Washington St., 3rd Floor Phoenix, AZ 85003 Attn: John R. Brean, P.E. After receipt of letter, I’ll obtain signatures from the WSD representative and the City of Phoenix County Health Delegate. Thank you and have a good day. Sincerely, John R. Brean, P.E. Mechanical Plans Engineer City of Phoenix Planning and Development Department 200 W. Washington St., 3rd Floor Phoenix, AZ 85003 Office: (602) 534-7265

Private Sewer

Application for Construction

Page 1 of 3 An applicant may receive a clarification from the city of its interpretation or application of a statute, ordinance, code or authorized substantive policy statement. To request clarification or to obtain further information on the application process and applicable review time frames, please call 602-262-7811 or visit our website at http://phoenix.gov/pdd/licensetimes.html. This publication can be made available in alternate formats (Braille, large print, or digital media) upon request. Contact Planning & Development at (602) 262-7811 voice or (602) 534-5500 TTY.

S:\Sewer Private, Application for Construction TRT/DOC/00210 WEB\ dsd_trt_pdf_00210 Rev. 11/12

APPLICATION FOR CONSTRUCTION AUTHORIZATION AND/OR NOTICE OF INTENT TO

DISCHARGE FOR A PRIVATELY OWNED SEWAGE COLLECTION SYSTEM CONSTRUCTED UNDER A TYPE 4.01

GENERAL PERMIT Complete and submit this form to obtain authorization to construct a privately owned sewage collection system under General Aquifer Protection Permit 4.01 (Arizona Administrative Code (AAC) R18-8-E30) and Maricopa County Health Code. Instructions are on Page 3. APPLICATIONS WILL NOT BE ACCEPTED UNLESS FULLY COMPLETED. Submit a separate Application for Construction Authorization/Notice of Intent to Discharge to the Water Services Department for sewage lift stations, force mains and gravity sewer mains grater then 12-inches in diameter. Any changes in the approved construction-ready plans that require additional plan review after issuance of the Construction Authorization will require a re-issuance of the Construction Authorization. PROJECT NAME PROJECT LOCATION

___________________________________________

___________________________________________

COP Project (KIVA) No. ________________________

Nearest Intersection: ___________________________

City Quarter Section Number(s): __________________

Section, Township, Range: ______________________

PROJECT APPLICATION ENGINEER INFORMATION

Name: ______________________________________

Firm: _______________________________________

Address: ____________________________________

___________________________________________

Phone: _____________________________________

Fax: _______________________________________

Name: ______________________________________

Firm: ________________________________________

Address: _____________________________________

____________________________________________

Phone: ______________________________________

Fax: ________________________________________ Project Description including title of plat and legal description with Section, Township and Range:

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

City of Phoenix Planning & Development Department Private Sewer, Application for Construction – Page 2 of 3 TRT/DOC/00210

SEWER SYSTEM DESIGN

Quantities: Population served by proposed system _____ persons Number of service connections _____ Number of manholes _____ Design flow of system at downstream point _____ gpd

Sewer Main L.F. _______ Size ______ in L.F. _______ Size ______ in L.F. _______ Size ______ in Force mains L.F. _______ Size ______ in

CONSTRUCTION SCHEDULE

Estimated Start Date: _______________________________ Estimated Completion Date: _________________

The following submittal requirements for Construction Authorization are attached or completed:

Engineer’s Design Report. The design report shall provide daily sewer flows including the basis for the calculations; describe the proposed construction and basis of design; provide design data and hydraulic calculations; and establish the adequacy of the design of the sewer collection system to meet expected flows. PDD will confirm with the Water Services Department that there is capacity in the existing treatment plants and collection system to receive the flows from the proposed sewage collection system. Design reports shall be signed and sealed by an Arizona registered professional engineer.

Complete Construction-Ready Design Plans. Plans shall be signed and sealed by an Arizona registered professional engineer.

Operations and Maintenance Plan. An O&M manual shall be prepared and provided to the owner/operator of the sewage collection system.

Certified Operator of System. The required O&M manual shall list an ADEQ certified sewage collection system operator at the appropriate grade based on A.A.C R18-5-114. The name, firm, address and 24-hour telephone number for the certified operator(s) of the system(s) shall be provided.

CC&R’s. Draft CC&Rs shall provide evidence of financial provisions regarding the operation, maintenance and replacement responsibility of the sewage collection system by the Homeowners Association (HOA) or other ownership group.

Other __________________________________________________________________________________ Certification of Compliance I certify that this Application For Construction Authorization under APP General Permit 4.01 and all attachments were prepared under my direction or authorization and all information is, to the best of my knowledge, true, accurate and complete. I certify that the sewage collection system described in this form will be designed and constructed in accordance with the approved plans and specifications; the terms and conditions of General Aquifer Protection Permit 4.01 (ACC R18-9-E301); the applicable requirements of Arizona Revised Statues, Title 49, Chapter 2; Arizona Administrative Code, Title 18, Chapter 9 regarding Aquifer Protection Permits; and Maricopa County Environmental Health Code Chapters II and V. I am aware that there are significant penalties for submitting false information including permit revocation as well as the possibility of fine and imprisonment for knowing violations. ___________________________________________________ _________________________

Signature of Applicant Date ___________________________________________________

Printed Name of Applicant

City of Phoenix Planning & Development Department Private Sewer, Application for Construction – Page 3 of 3 TRT/DOC/00210

INSTRUCTIONS FOR COMPLETING FORM Project Name: The Project Name should match the name as specified on the related plans and the recorded subdivision plat. COP Project Number: Provide the “KIVA” number that was provided by the Planning and Development Department. Project Location: Indicate the nearest major intersection. Project Applicant: The person named on the form must be the owner of the project or a person with fiduciary responsibility with an established legal entity (e.g. corporation, LLC partnership). Only the owner or a person with fiduciary responsibility for the entity can be issued a permit, or can be inclusively viewed as responsible for compliance. Engineer Information: Name of Engineer must be an Arizona Registered Professional Engineer (in active status) with an Arizona Registered Engineering Firm. Privately Owned AP 4.01 Sewage Collection System: Complete this application if proposed sewage collection system falls under the requirements of Arizona’s Protection Permit (APP) General Permit 4.01 (AAC R18-9-E301) but will be privately owned and operated. APP General Permit rules require 4.01 General Permit compliance for sewage collection systems that serve multiple private users where the individual users assume ownership and control to the downstream point where the sewer delivers wastewater to a sewage collection system owned and controlled by a public sewer utility. General Permit 4.01 is applicable if the private sewage collection system is constructed outside the footprint of the served building(s) and collects wastewater into a system accommodating a design flow of 3, 000 gallons per day (gpd). Project Description: Clearly state the scope of the project and how the project relates to the subdivision plat. This field will be used to match the permits issued with the approved plat when an Approval of Sanitation Facilities for Subdivision is requested from the Maricopa County Department of Environmental Services (a.k.a. Health Certificate) for the Arizona Department of Real Estate, Subdivision Public Report. Quantities: Indicate the total estimated population that will be served by the system, the number of service connections, the number of manholes, and the design flow at the downstream point. Estimate the lengths of sewer main to be constructed. Schedule: Entries for estimated start date and estimated completion date are restricted by County and State code. Estimated construction start must be within one year of granting approval and estimated completion shall be no less than two years from granting approval. Required Attachments: Instructions are provided in that section of form. Certification of Compliance: This certification must be signed by the project applicant who is the person responsible for compliance. The person named on the form must be the owner of the project or a person with fiduciary responsibility with an established legal entity (e.g. corporation, LLC, partnership). This person’s name will be on the approval certificate (or issued the permit).

Private Sewer

Construction Authorization

Page 1 of 1 This publication can be made available in alternate formats (Braille, large print, computer diskette, or audiotape) upon request. Contact Planning and Development at (602) 262-7811 voice or (602) 534-5500 TTY.

FOR A PRIVATELY OWNED SEWAGE COLLECTION SYSTEM CONSTRUCTED UNDER A TYPE 4.01

GENERAL PERMIT The proposed sewage collection system falls under the requirements of Arizona’s Aquifer Protection Permit (APP) General Permit 4.01 (AAC R18-9-E301) and Maricopa County Health Code but will be privately owned and operated. A new Construction Authorization will be required for any changes in the approved construction-ready plans that require additional plan review. PROJECT NAME PROJECT INFORMATION

___________________________________________

___________________________________________

___________________________________________

COP Project (KIVA) No. _______________________

LPR ______ No. _____________________________

SDEV No. __________________________________

PROJECT APPLICANT ENGINEER INFORMATION

Name: _____________________________________

Firm: ______________________________________

Address: ___________________________________

___________________________________________

Name: _____________________________________

Firm: ______________________________________

Address: ___________________________________

___________________________________________ Project Description including title of plat and legal description with Section, Township and Range: __________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________ Checklist for Construction Authorization (verify all items are completed at time of submittal)

Request for Construction Authorization submitted and completed. Engineer’s Design Report submitted and completed. PDD has confirmed with WSD that there is capacity in existing treatment plants and collection system to

receive flows from the proposed sewage collection system _______________________ ____________ WSD Representative Date

Approved design and specifications submitted, signed and sealed by an Arizona registered professional engineer.

O&M Plan submitted to owner/operator of sewage collection system. Draft CC&R’s or letter submitted for private owned sewer systems providing evidence of financial provisions. Other __________________________________________________________________________________

The Construction Authorization is issued in accordance with Arizona Administrative Code, AAC Title 18 Chapter 9, Article 3; and Maricopa County Environmental Health Code Chapters II or V. The applicant is authorized to construct the above described facilities in accordance with the approved plans and specifications, the requirements of 4.01 General Permit (for sewage collection systems), and applicable requirements of AAC Title 18, Chapter 9, Article 3; and Maricopa County Environmental Health Code Chapters II or V. Construction shall start within one year and be completed within two years of this approval date or this document shall be voided unless a time extension is requested and approved in writing. ____________________________________________ _________________________

City of Phoenix County Health Delegate Date

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OUTLINE – SEWER DEMAND REPORT

Sewer Demand Report

I. Introduction

II. Project Description

III. Sanitary Sewer System

IV. Sanitary Sewer Calculations

V. Sanitary Pump Station Calculations (If Applicable)

Operations and Maintenance Manual

I. Introduction

II. Site Location

III. Sewer System Description

IV. Contact Information and Responsible Parties

V. Provide general requirements and proof of certification for sewer operator (Arizona

Administrative Code Title 18, Chapter 5 Article 1)

VI. Operation and Maintenance (O&M) Program

VII. Repairs

VIII. Inspections (Visual and Video Camera)

IX. Cleaning

X. Odor Control

XI. Root Control

XII. Vermin and Insect Control

Safety Guidelines

1. OSHA and Arizona Division of Occupational Safety and Health (ADOSH)

2. Hazardous Area Classifications

3. Excavations

4. Traffic and Pedestrian

5. Manhole

6. Recordkeeping

Emergency Conditions

1. 24 hr, emergency contact, map of sewer system posed on premise, tenant notification

2. Spill and Overflow Procedures

3. Service and repair request

If you have any additional questions or comments, please feel free to contact me at any time.

John R.Brean, P.E.

Mechanical Plans Engineer

City of Phoenix, Planning and Development Department

200 W. Washington St., 3rd Floor Phoenix, AZ 85003 Office: (602) 534-6498

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OWNER ADVISORY AND AUTHORIZATION FOR LOW SLOPE SEWER INSTALLATION

THIS FORM IS NOT OFFICIAL UNTIL COMPLETED AND ACCEPTED BY THE CITY OF PHOENIX

Project Number:

Date:

Owners Name: Project Address:

Owner acceptance of low slope sewer per engineered design: The Plumbing Code establishes minimum slopes for onsite building sewers. Due to site conditions, which make standard pipe slopes impractical or impossible, a Professional Engineer has proposed a slope which is less than standard minimum pipe slopes. In full recognition that this alternative proposal may result in increased maintenance and operating costs, I, as owner, am willing to accept this non-standard installation. Dated: _______________________________ Signature of Owner: ________________________________ State of: ______________________________ County of: ________________________________________

Subscribed and sworn before me this ________________ day of ________________________________, 20_____

by _________________________________________.

Notary Public: _____________________________________

My Commission Expires: ____________________________

(Seal) Design Engineer’s Statement, Seal, and Signature: In my professional opinion, the alternative building sewer

installation proposal submitted with this request will perform satisfactorily, will achieve the objectives of those Plumbing Code Sections applicable to sewer installations, and will do so with a minimal increase in maintenance requirements. The installation and inspection of this sewer will be under my supervision.

(Seal, Sign, and Date) Statement of Compliance: I certify that the alternative sewer design, as submitted,

was installed, inspected, and is compliant with both my alternative engineered design and all other applicable code sections regarding sewer pipe sizing, bedding, materials, cleanouts, backfilling, etc.

(Seal, Sign, and Date)

LOW SLOPE SEWER INSTALLATION CERTIFICATE PROCEDURE

The 2012 Uniform Plumbing Code (UPC) Section 718.1 and the 2012 International Plumbing Code (IPC) Section 704.1 require a minimum slope of one-fourth (1/4) inch per foot of horizontal run. If sewer slopes are proposed which are less than UPC or IPC approved values, an Owner Advisory and Authorization for Low Slope Sewer Installation Certificate is to be approved by the Planning & Development Department (P&D) and Special Inspection is required by the design engineer. Additionally, there will be P&D inspections to determine whether the pipe sizing, cleanouts, material, support, alignment, and transition methods utilized by the installer are code compliant. 1. Provide substantial documentation justifying why it is impossible to provide code compliant

grades for the building sewer lines and justify why the proposed low slope sewer design should be considered an equivalent alternative to the UPC or IPC, lift station, lowering of sewer taps, or other.

2. If P&D concurs with your written justification for a low slope sewer, you may complete and

submit an Owner Advisory and Authorization for Low Slope Sewer Installation Certificate. A blank form may be obtained from the plan reviewer, field inspector or office staff.

3. Complete the job information boxes on the form including project number, date, owner’s

name and project address. 4. Provide a notarized signature of the project owner at the Owner acceptance of low slope per

engineered design portion located on the form. If an agent for the owner is to sign (and notarize), a notarized power of attorney by the owner shall be attached to the certificate.

5. The design engineer is to date, sign and seal the Design Engineer’s Statement, Seal and

Signature portion of the form. 6. Make a photocopy of the partially completed Low Slope Sewer Installation Certificate at this

point and provide it to the plan reviewer, field inspector or other P&D personnel you are working with for their approval.

7. After approval is granted by the plumbing plan reviewer, plumbing field inspector or other

P&D personnel and permits are obtained, you may proceed with the installation of the low slope sewer. Do not backfill any piping without Field Inspector approval.

8. When the sewer is installed and trenches are open, the design engineer who signed the

original certificate or his delegate shall perform a visual inspection of the sewer and confirm the alignment and grades proposed. When the design engineer is satisfied with the installation the Statement of Compliance section on the original form shall be dated, signed and sealed by the design engineer. Verify with the Plumbing Field Inspector at this time if it will permissible to backfill the trench.

9. The completed document will be treated as a Special Inspection Certificate. A copy shall be

returned to P&D for our permanent records prior to Final Inspection, Certificate of Completion or Certificate of Occupancy of the project.