DNR Form 542-3079 Schedule Z "Wastewater Treatment and Disposal Systems Site Selection" - Iowa

What Is DNR Form 542-3079 Schedule Z?

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 August 1, 2018;
  • 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 542-3079 Schedule Z 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 542-3079 Schedule Z "Wastewater Treatment and Disposal Systems Site Selection" - Iowa

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DNR USE ONLY
Iowa Department of Natural Resources
Project No.
Wastewater Section
Construction Permit Application
Permit No.
SCHEDULE Z, Wastewater Treatment and Disposal Systems Site Selection
Date Prepared
Project Identity
Date Revised
1. Site survey conducted by:
2. Professional site survey information included
Yes
No
3.
Project Location
County:
Section:
Township:
Range:
Is this a:
New Site
Existing Site
Expansion of Existing Site
4. Provide the following as attachments (minimum two copies each):
a. General play layout of area within a five miles radius of the project location, noting all important features (USGS map may be
used).
b. Site layout within a 1,500 foot radius of the proposed project site with a scale of 1 inch equal to 200 feet, noting proposed
site. Note site and all features listed in:
i. Subrule 567 IAC 64.2(3): for Wastewater Treatment and Storage Facility sites.
ii. Iowa Wastewater Design Standards Chapter 21: for Wastewater Land Application sites.
5. Does the project lie in a flood plain?
Yes
No
Elevation of 100 year flood (MSL):
Elevation of 25 year flood (MSL):
6. Minimum depth to high water table:
7. Describe geology of area:
8. Describe soil conditions:
9. State the minimum distances and directions from project site to:
a. Public shallow wells
b. Public deep wells
c. Private wells
d. Inhabitable residences, commercial buildings, or other inhabitable structures
e. Lakes and public impoundments
f. Property lines and public road rights-of-way
g. Flowing stream
h. Public lake or impoundment used as potable water source
i. Other
10. Where any of the separation distance criteria of Subrule 567 IAC 64.2(3) and/or Iowa Wastewater Design Standards Chapter 21
will not be met, state the basis for requesting site approval (e.g. a written agreement with the owner of the inhabitable building
has been obtained).
11. Will warning signs be provided at 500 foot maximum intervals for Land Application sites?
Yes
No
If no, explain:
12. Direction of prevailing winds:
13. Is land area available for expansion?
Yes
No If yes, how much?
Description of expansion area?
Property Owner:
14. Will site be accessible via an all-weather access road?
Yes
No
Type:
Complete separate Schedule Z for each separate project site.
08/2018 cmc
DNR Form 542-3079
DNR USE ONLY
Iowa Department of Natural Resources
Project No.
Wastewater Section
Construction Permit Application
Permit No.
SCHEDULE Z, Wastewater Treatment and Disposal Systems Site Selection
Date Prepared
Project Identity
Date Revised
1. Site survey conducted by:
2. Professional site survey information included
Yes
No
3.
Project Location
County:
Section:
Township:
Range:
Is this a:
New Site
Existing Site
Expansion of Existing Site
4. Provide the following as attachments (minimum two copies each):
a. General play layout of area within a five miles radius of the project location, noting all important features (USGS map may be
used).
b. Site layout within a 1,500 foot radius of the proposed project site with a scale of 1 inch equal to 200 feet, noting proposed
site. Note site and all features listed in:
i. Subrule 567 IAC 64.2(3): for Wastewater Treatment and Storage Facility sites.
ii. Iowa Wastewater Design Standards Chapter 21: for Wastewater Land Application sites.
5. Does the project lie in a flood plain?
Yes
No
Elevation of 100 year flood (MSL):
Elevation of 25 year flood (MSL):
6. Minimum depth to high water table:
7. Describe geology of area:
8. Describe soil conditions:
9. State the minimum distances and directions from project site to:
a. Public shallow wells
b. Public deep wells
c. Private wells
d. Inhabitable residences, commercial buildings, or other inhabitable structures
e. Lakes and public impoundments
f. Property lines and public road rights-of-way
g. Flowing stream
h. Public lake or impoundment used as potable water source
i. Other
10. Where any of the separation distance criteria of Subrule 567 IAC 64.2(3) and/or Iowa Wastewater Design Standards Chapter 21
will not be met, state the basis for requesting site approval (e.g. a written agreement with the owner of the inhabitable building
has been obtained).
11. Will warning signs be provided at 500 foot maximum intervals for Land Application sites?
Yes
No
If no, explain:
12. Direction of prevailing winds:
13. Is land area available for expansion?
Yes
No If yes, how much?
Description of expansion area?
Property Owner:
14. Will site be accessible via an all-weather access road?
Yes
No
Type:
Complete separate Schedule Z for each separate project site.
08/2018 cmc
DNR Form 542-3079
Instructions for Schedule Z
1. Identify who will conduct site survey- IDNR field office or Professional Land Surveyor and company name.
2. Include survey report with full legal description.
3. Site location and type.
4. Important features which include public shallow wells, public deep wells, private wells, inhabitable residences,
commercial buildings, or other inhabitable structures, lakes, public impoundments, and other public use or
recreation areas, property lines, and rights‐of‐way, and any other feature affected by the water quality shall be
included on the 1500 foot radius site layout.
5. Self‐explanatory.
6. Indicate minimum depth to typical wet weather groundwater level.
7. Description of landforms and geologic features of the site. Include depth to bedrock, presence of impermeable
layers, and land slope at site.
8. List dominant soil type, hydrologic class, saturated conductivity, and salinity classification in accordance with
Iowa Wastewater Design Standards Chapter 21.1.3.
9. State minimum distances from site to features within a 1,500 foot radius.
10. See subrule 567 IAC 64.2(3) of the Iowa Administrative Code and/or Iowa Wastewater Design Standards Chapter
21 for the required separation distances. When the separation distances in the referenced rules cannot be
maintained for the expansion, upgrading or replacement of existing wastewater treatment and storage facilities,
the separation distances shall be maintained at no less than 90 percent of the existing separation distance on
the site, providing no data is available indicating that a problem has existed or will be created. If requesting the
90 percent exception, the proposed separation distance from each potentially affected item or structure shall be
identified on Schedule Z or an attachment to the form.
The 90 percent exception criteria does not apply to new treatment plants at a new site.
11. Self‐explanatory.
12. Self‐explanatory.
13. Self-explanatory.
14. Self‐explanatory.
08/2018 cmc
DNR Form 542-3079
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