DNR Form 542-1541 "Notice of Intent to Be Covered Under Npdes General Permit No. 4 '"discharge From Private Sewage Disposal Systems'"" - Iowa

What Is DNR Form 542-1541?

This is a legal form that was released by the Iowa Department of Natural Resources - a government authority operating within Iowa. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2010;
  • The latest edition provided by the Iowa Department of Natural Resources;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of DNR Form 542-1541 by clicking the link below or browse more documents and templates provided by the Iowa Department of Natural Resources.

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Download DNR Form 542-1541 "Notice of Intent to Be Covered Under Npdes General Permit No. 4 '"discharge From Private Sewage Disposal Systems'"" - Iowa

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IOWA DEPARTMENT OF NATURAL RESOURCES ENVIRONMENTAL
SERVICES DIVISION
NOTICE OF INTENT
TO BE COVERED UNDER NPDES GENERAL PERMIT No. 4
“DISCHARGE FROM PRIVATE SEWAGE DISPOSAL SYSTEMS”
(Type or Print)
Address
City
Current Owner
State
Zip
Telephone
(
)
Has this private sewage disposal system been previously covered by General Permit #4?
Yes
No
If yes, please list authorization number:
and then proceed to Certification
Section at the bottom of this form
If no, please provide the following location information:
Location of sewer system: (
)
Required. If “same as above”, please write “same”
Street address
City
Zip
Legal description: (required unless lat./long. available)
¼ of
¼ of
¼ of Sec.
,T
N, R
W
E
¼ Section
¼ Section
¼ Section
Section
Township
Range
County (required):
Latitude: (if available)
(Deg./decimal-deg.)
Longitude:
Sand Filter (buried)
Sand Filter (free access)
Mechanical/Aerobic Unit
Type of Secondary Treatment:
Constructed Wetland
Lagoon
Other
(describe)
Certification: For existing private sewage disposal systems, check off the first two items below. For
new installations, check off all three items below:
I certify the above information is true and accurate, to the best of my knowledge.
I agree to abide by all terms and conditions of the DNR NPDES General Permit #4.
I certify that the permitted system will be constructed in conformance with the requirements of IAC 567 -
Chapter 69 and all applicable County requirements.
Signature
Date
Send completed form to:
NPDES Section
A copy of the permit will be mailed to you along with your discharge authorization.
Iowa Department of Natural Resources
502 E 9
Street
th
Des Moines, IA 50319
12/2010 cmz
DNR Form 542-1541
Print Form
IOWA DEPARTMENT OF NATURAL RESOURCES ENVIRONMENTAL
SERVICES DIVISION
NOTICE OF INTENT
TO BE COVERED UNDER NPDES GENERAL PERMIT No. 4
“DISCHARGE FROM PRIVATE SEWAGE DISPOSAL SYSTEMS”
(Type or Print)
Address
City
Current Owner
State
Zip
Telephone
(
)
Has this private sewage disposal system been previously covered by General Permit #4?
Yes
No
If yes, please list authorization number:
and then proceed to Certification
Section at the bottom of this form
If no, please provide the following location information:
Location of sewer system: (
)
Required. If “same as above”, please write “same”
Street address
City
Zip
Legal description: (required unless lat./long. available)
¼ of
¼ of
¼ of Sec.
,T
N, R
W
E
¼ Section
¼ Section
¼ Section
Section
Township
Range
County (required):
Latitude: (if available)
(Deg./decimal-deg.)
Longitude:
Sand Filter (buried)
Sand Filter (free access)
Mechanical/Aerobic Unit
Type of Secondary Treatment:
Constructed Wetland
Lagoon
Other
(describe)
Certification: For existing private sewage disposal systems, check off the first two items below. For
new installations, check off all three items below:
I certify the above information is true and accurate, to the best of my knowledge.
I agree to abide by all terms and conditions of the DNR NPDES General Permit #4.
I certify that the permitted system will be constructed in conformance with the requirements of IAC 567 -
Chapter 69 and all applicable County requirements.
Signature
Date
Send completed form to:
NPDES Section
A copy of the permit will be mailed to you along with your discharge authorization.
Iowa Department of Natural Resources
502 E 9
Street
th
Des Moines, IA 50319
12/2010 cmz
DNR Form 542-1541