DEQ USE REGIONAL OFFICE

Received ______

App No. ______

File No. ______

EPA No. ______

Mail ID #2/#9 ______

Hydrocode ______

DOC Conf. ______

Application

WPCF (1000)

Water Pollution Control Facilities Permit

State of Oregon

DOGAMI USE

Amt Received ______

DEQ-WQ\PPD\WC15\WC15235.doc – OVER – P:\DEQ Forms\3 Application - 1000 WPCF (REVISED 09-2010 fees)

A. REFERENCE INFORMATION

DEQ-WQ\PPD\WC15\WC15235.doc – OVER – P:\DEQ Forms\3 Application - 1000 WPCF (REVISED 09-2010 fees)

1. Applicant ______

2. Mailing Address ______

City/State/Zip ______

3. Responsible Official ______

Title ______

Address ______

Phone ______

4. DOGAMI ID No. ______

5. Alternate

Responsible Official ______

Title ______

Address ______

Phone ______

6. Facility Name ______

7. Site Location ______

if different than #2 ______

8. DOGAMI will

provide the Latitude ______Longitude ______

DEQ-WQ\PPD\WC15\WC15235.doc – OVER – P:\DEQ Forms\3 Application - 1000 WPCF (REVISED 09-2010 fees)

B. GENERAL DESCRIPTION OF FACILITY

Briefly, summarize the proposed facility and primary method of wastewater treatment and disposal.

______

______

C. REQUIRED EXHIBIT

As EXHIBIT A, attach two copies of a Preliminary Engineering Report or Facility Plan Report that fully describes the proposed project, using written discussion, maps, diagrams, and any other necessary materials. Specific items contained in the report should include:

DEQ-WQ\PPD\WC15\WC15235.doc – OVER – P:\DEQ Forms\3 Application - 1000 WPCF (REVISED 09-2010 fees)

1.  A complete description of the proposal.

2.  The location of the project and adjacent facilities and waterways.

3.  Schedule for development.

4.  Disposal of solid waste and sludges.

5.  Schematic diagrams of industrial processes, waste streams, and treatment and disposal facilities.

6.  Ground water information.

7.  Evaluation of ground water and surface water impacts.

DEQ-WQ\PPD\WC15\WC15235.doc – OVER – P:\DEQ Forms\3 Application - 1000 WPCF (REVISED 09-2010 fees)

D. LAND-USE APPROVAL

The Land-Use Compatibility Statement: o is attached owill be sent separately oN/A

E. OTHER PERMITS

Attach a list of other permits issued or applied for.

F. FEES – MUST ACCOMPANY THIS APPLICATION

Application Processing Fee $198

Annual Compliance Fee 448

Total $646

G. SIGNATURE

I hereby certify that the information contained in this application is true and correct to the best of my knowledge and belief.

______

Signature of Legally Authorized Representative Title Date

(See instructions for definitions.)


instructions

A. REFERENCE INFORMATION

1. Enter the applicant's official or legal name. Do not use a colloquial name. If a partnership, list each partner.

2. Enter the mailing address where the permit and related correspondence should go.

3. Give the name of the responsible official we should contact if we have questions about the application or the facility.

4. Provide the DOGAMI ID No. for this site.

5. List an alternate to the official named in Item 3.

6. Facility Name.

7. Enter the address of the facility if different from the mailing address in Item 2.

8. DOGAMI will provide the latitude and longitude.

B. GENERAL DESCRIPTION OF FACILITY

Please enter a general description of the proposed facility and the primary method of handling wastewater.

Examples:

1. 2 MGD Domestic Sewage Treatment Plant consisting of non-overflow, evaporative lagoons.

2. Seasonal jam and jelly processing facility with land irrigation of process wastewater.

C. REQUIRED EXHIBIT
NOTE: Exhibit A is the most important part of the application. Failure to provide the required information will delay processing the application and final action on permit issuance.

1. A facility description should include all aspects of the proposed facility including all products to be manufactured, services to be rendered, or activities to be conducted.

2. A facility description should include a map, which not only shows the location and expanse of the project but also the location of adjacent waterways, drainage ways, residential areas and industrial or commercial facilities. Please locate project by Township, Range, and 1/4 – 1/4 section.

3. The proposed development and construction schedule should be as complete and accurate as possible. This should include future expansion plans or potential.

4. Schematics should include each waste stream (including a water balance), treatment and control facilities, and ultimate disposal means of each waste product or effluent. Alternatives for treatment, if being considered, should also be included. Where possible, the quantity and quality of each waste stream should be noted.

5. The collection, storage and disposal of sludges should be addressed, including volume and quality where possible.

6. Ground water information must be provided for all areas where wastewater or sludge will be stored or disposed. The following minimum information is required: (In areas of shallow, unprotected aquifers or other areas with high potential for groundwater contamination, additional information may be required.)

a. Climatic information.

b. Topography and soil profile description.

c. Flooding and erosion potential.

d. Groundwater aquifer characteristics, including quality and gradient.

e. Location of all wells and springs within 1/2-mile radius.

7. Provide information detailing steps to be taken in protecting surface and ground water during construction and operation of the facility.

D. LAND-USE APPROVAL

The Department will not process a permit application without evidence that the proposal is approved by local land use planning agencies and meets statewide planning goals. The attached compatibility statement may be used for that evidence.

E. OTHER PERMITS

In order for the Department to coordinate with other agencies and other Divisions within the agency, it is important to provide information regarding the status of other applications or permits.

F. FEES

Please make check payable to DOGAMI and return with completed application to:

DOGAMI, 229 Broadalbin Street SW, Albany OR 97321

G. SIGNATURE

If the applicant is: / The “Legally Authorized Representative” is:
a Corporation / a principal executive officer of at least the level of vice president
a Partnership or Sole Proprietorship / a general partner or the proprietor (owner), respectively
a Municipality, State, Federal, or other Public Facility / a principal executive officer or a ranking elected official
a Limited Liability Company / a member
a Trust / an acting trustee

DEQ-WQ\PPD\WC15\WC15235.doc – OVER – P:\DEQ Forms\3 Application - 1000 WPCF (REVISED 09-2010 fees)