"Application for New Water Pollution Control Facilities Individual Onsite Permit" - Oregon

Application for New Water Pollution Control Facilities Individual Onsite Permit is a legal document that was released by the Oregon Department of Environmental Quality - a government authority operating within Oregon.

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DEQ USE ONLY
DEQ USE ONLY
Application #
Date Received:
Total Amount Received:
File#
WPCF-OS
Add. Amt. Due (if any):
Mail ID #2/#9
Application for New Water
#
LLID/RM:
Deposit #
ACD
Fee
Paid:
Pollution Control Facilities
Receipt #
DOC Conf:
Individual Onsite Permit
Notes:
IND
DOM
OSS Surcharge:
See pages 4-6 for detailed instructions
A. Reference Information
1. Legal Name of Applicant:
2. Is the name of the applicant the owner of the facility?
Yes
No
3. Legal Status of Applicant:
Federal
State
Public
Private
Other
4. (specify): Name of Facility (if different than legal name):
5. Facility SIC Code:
or, NAICS code:
B. Facility Location
1.
Physical Street Address:
City:
State:
ZIP Code:
County:
2.
3.
Range:
Latitude:
degrees
minutes
seconds
Township:
Longitude:
degrees
minutes
seconds
Section:
Tax Lot #
C. Facility Contacts
1. Responsible Official
Full Name:
Telephone #:
Mailing Address:
City:
State:
Zip Code:
Email Address:
2. Facility Contact
Full Name:
Telephone #:
Mailing Address:
City:
State:
Zip Code:
Email Address:
3. Invoice to
Full Name:
Telephone #:
Billing Address:
City:
State:
Zip Code:
DEQ USE ONLY
DEQ USE ONLY
Application #
Date Received:
Total Amount Received:
File#
WPCF-OS
Add. Amt. Due (if any):
Mail ID #2/#9
Application for New Water
#
LLID/RM:
Deposit #
ACD
Fee
Paid:
Pollution Control Facilities
Receipt #
DOC Conf:
Individual Onsite Permit
Notes:
IND
DOM
OSS Surcharge:
See pages 4-6 for detailed instructions
A. Reference Information
1. Legal Name of Applicant:
2. Is the name of the applicant the owner of the facility?
Yes
No
3. Legal Status of Applicant:
Federal
State
Public
Private
Other
4. (specify): Name of Facility (if different than legal name):
5. Facility SIC Code:
or, NAICS code:
B. Facility Location
1.
Physical Street Address:
City:
State:
ZIP Code:
County:
2.
3.
Range:
Latitude:
degrees
minutes
seconds
Township:
Longitude:
degrees
minutes
seconds
Section:
Tax Lot #
C. Facility Contacts
1. Responsible Official
Full Name:
Telephone #:
Mailing Address:
City:
State:
Zip Code:
Email Address:
2. Facility Contact
Full Name:
Telephone #:
Mailing Address:
City:
State:
Zip Code:
Email Address:
3. Invoice to
Full Name:
Telephone #:
Billing Address:
City:
State:
Zip Code:
Legal Name of Applicant:
D. General Information
1. Briefly describe the proposed facility, type of wastewater, and primary method of wastewater treatment and disposal:
What is the projected daily sewage flow for each system included in the application?
What is the combined projected daily sewage flow for the facility?
2. Is the proposed facility located within a half-mile of an area wide
Yes
No
community sewerage system?
If "Yes", how close is the nearest connection point to the sanitary sewer:
3. Does the proposed facility described in D.1 discharge wastewater to an Underground
Yes
No
Injection Control (UIC) system?
4. Is there any other wash water or wastewater that will be or is being discharged to a UIC
Yes
No
system not described in D.1? If "Yes", also provide the information required in Section F,
Project Description and Facility Plans for each UIC.
5. Does or will stormwater at the facility be drained to a UIC system other than described by
Yes
No
this application? If "Yes", also complete UIC Registration Form: Stormwater Drainage
Systems.
E. Other DEQ or Public Agency Permits
List all other DEQ or public agency permits issued to or applied for this project:
F. Project Description and Facility Plans
Attach two copies of a project plans and specifications that fully describes the proposed project using a narrative
description, maps, diagrams, and any other necessary materials. The report must contain the following information
(see instructions for more detail):
1. Complete description of the proposal.
2. Location of the project, adjacent facilities, and waterways on a USGS topographic map. Include the location and latitude/
longitude for all UIC wastewater systems on this map.
3. Also provide a tax lot map for the project.
4. Schedule for development, including future expansion plans if applicable.
5. Schematic diagrams of waste streams and treatment/disposal facilities. Include the source and quantity of drinking water
and water used for processing or manufacturing.
6. Wastewater characterization.
7. Site evaluation report prepared as outlined by OAR 340-071-0150.
8. Groundwater information for all areas where wastewater will be treated or disposed.
9. Evaluation of groundwater and surface water impacts and the steps that will be taken to prevent impacts from occurring as
outlined by OAR 340-071-0520. 12/2/2020: Updated instructions on Page 5
10. Operation and maintenance plan that specifies the normal operation parameters of the system.
G. Land Use Compatibility Statement
Attach a complete Land Use Compatibility Statement (LUCS) signed by the local land use authority. The application will not
be processed without evidence that the proposal is approved by the local land use authority and meets statewide planning
goals.
H. Underground Injection Control (UIC) Registration
Federal and state regulations require that all UIC systems be registered with DEQ. By completing this application, your
wastewater UIC systems will be registered with DEQ and you will be sent a UIC registration confirmation letter to be
maintained at the facility. You will be informed by DEQ of any additional UIC regulations that are applicable to your UIC
system once this application has been reviewed.
Page 2 of 6
Legal Name of Applicant:
I. Signature of Legally Authorized Representative
I hereby certify that the information contained in the application is true and correct to the best of my knowledge and belief. In
addition, I agree to pay all permit fees required by Oregon Administrative Rule 340-071. This includes a new application fee to
obtain the permit and a compliance determination fee invoiced annually by DEQ to maintain the permit.
Legally Authorized Representative (Type or Print):
Title:
Signature of Legally Authorized Representative:
Date:
Page 3 of 6
Application Instructions for New WPCF-OS Permit
Please answer all questions and submit with the required application fees.
An incomplete application or incorrect fees will not be processed. If the information requested is not applicable,
please indicate as such.
A. Reference Information
1. Enter the legal name of the applicant. The permit will be issued to this entity. This is the person, business,
public organization, or other entity that controls the facility described in this application and will be
responsible for complying with the conditions of the permit. This must be the legal Oregon name (i.e., Acme
Products, Inc.) or the legal representative of the company if it operates under an assumed business name
(i.e. John Smith, dba Acme Products). The name must be a legal active name registered with the Oregon
Department of Commerce, Corporation Division (503-986-2200), unless otherwise exempted by their
regulations
2. Indicate if the applicant is the owner of the facility.
3. Provide the legal status of the applicant. Indicate "public" for a facility solely owned by local government.
4. Enter the common name of the facility or operation if different from the legal name of the applicant.
5. Enter the Standard Industrial Classification (SIC) four-digit code or North American Industry Classification
System five or six-digit code (NAICS) for the facility. These codes are used to describe the primary activity at
the facility and may be found on fire marshal reports, insurance papers, or tax forms. The NAICS codes
replaced the SIC system in 1997, however, it is usually easy to convert between the two systems so either
code is acceptable. SIC or NAICS information is also available from the U.S. Census Bureau at 1-888-756-
2427 or at http://www.naics.com/search.htm.
B. Facility Location
1. Enter the physical location of the facility (street address, not mailing address), including city, state, zip
code, and county.
2. Enter the latitude and longitude of the approximate center of the facility or site in degrees/minutes/seconds.
Latitude and longitude can be obtained from DEQ’s location finder web site at
https://www.oregon.gov/deq/wq/wqpermits/Pages/Tools-and-Data.aspx
or from United States Geological
Survey (USGS) quadrangle topographic maps by calling toll-free at 1-888-ASK-USGS (1-888-275-8747). For
obtaining latitude and longitude from USGS maps, instructions may be obtained from DEQ’s website at
http://www.oregon.gov/deq/FilterDocs/latlonginstr.pdf.
3. Enter the Township, Range, Section, and Tax Lot numbers for the regulated site.
C. Facility Contacts
1. Enter the name, telephone number, and mailing address of the Responsible Official. The Responsible
Official receives official correspondence from DEQ, such as renewal notices or violation notices, and
contacted if there are questions about this application.
2. Enter the name, telephone number and mailing address of the Facility Contact if different from the
Responsible Official. The Facility Contact is typically located at or near the facility and has specific
knowledge of the facility or operation under permit, such as the treatment plant operator, and may be
contacted if there are specific questions about this application.
3. Enter invoicing information for billing purposes if different from the Responsible Official, for example,
"Invoice To: Business Office - Accounts Payable".
D. General Information
1. Briefly describe the proposed facility, Source of wastewater, such as 20-space mobile home park with
laundry facilities, and primary method of wastewater treatment and disposal. For example, "5,000 gallon
per day recirculating gravel filter system followed by standard drainfields"
2. Indicate if a community sewer system is possibly available to serve this facility. If "yes," specify distance to
nearest connection point to sewer.
3. Indicate if an Underground Injection Control (UIC) system will be used or is currently used to dispose of
wastewater for the proposed facility described in D.1. Wastewater includes wash waster, process
wastewater, and/or sewage. The following wastewater disposal systems are considered UICs:
Non-residential onsite sewage system with a design flow of 2,500 gallons per day or designed to serve 20
or more people a day (excluding single-family residential systems)
Multi-family residential onsite sewage systems regardless of size
Any onsite sewage system, regardless of size, that receives industrial wastewater
Dry wells or sumps
Infiltration trenches
French drains
Industrial wastewater drain holes
Cesspools/sewage drain holes
4. Indicate if there is any other wash water or wastewater at the regulated site that will be or is being discharged to
a UIC system not included in the proposed facility description found in D.1. If "yes," also provide the
information required in Section F, Project Description and Facility Plans for each UIC.
5. Indicate if a UIC system other than the one described in this application will be used or is currently used to
drain storm water. The following storm drainage systems are considered UICs:
Any UIC wastewater system also used for storm damage
Dry wells or sumps
French drains
Infiltration trenches
Storm drain holes
Other DEQ or Public Agency Permits:
In order for DEQ to coordinate with other DEQ divisions and public agencies, list all permits issued to or
applied for this project.
F.
Project Description and Facility Plans:
Two copies of a Project Description and Facility Plans must accompany this application and contain the
following minimum information:
1. A description that includes all aspects of the facility, including services to be provided and activities to be
conducted.
2. A USGS topography map that shows the location and scope of the project, locations of adjacent facilities,
waterways, wetlands, drainage ways, residential areas, industrial facilities, and commercial areas, including
the location and latitude/longitude for all UIC wastewater systems. Also provide a tax lot map for the project.
4. The proposed development and construction schedule. Also include future expansion plans or potential plans.
5. Schematic diagrams that include each waste stream, collection facilities, treatment and control facilities,
and ultimate disposal methods for each system. If alternatives for treatment are also being considered,
they should be included as well. Plans and specifications must meet OAR 340-052, including the level of
detail and who may design the system or systems.
6. A characterization of the quantity and quality of each waste stream, including nitrogen and phosphorous.
7. For onsite sewage systems only, a site evaluation report prepared as outlined in OAR 340-071-0150 by a
DEQ Agent. The report shall contain, at a minimum, a site diagram and observations of the site
characteristics.
8. Groundwater information for all areas where wastewater or sludge will be stored or disposed. Also include
the source of drinking water for the facility being served. The following minimum information is required:
• Climatic information, including annual precipitation
• Groundwater aquifer characteristics, including quality and gradient
• Topography, flooding and erosion potential and NRCS soil profile description
• Hydrogeologic properties (transmissivity, hydraulic conductivity)
• Location of all wells and springs within a ½ mile radius (provide well logs and identify on map when
known)
• The source of drinking water for the facility being served (public water system number, if applicable)
In areas of shallow, unprotected aquifers or other areas with high potential for groundwater
contamination, additional information may be required (see
OAR
340-040-0030)
9. The applicant must provide a written assessment of the impact of the proposed system on the quality of
public waters and public health, prepared by a registered geologist, a certified engineering geologist
qualified as a hydrogeologist. We advise gathering and submitting this information prior to
submitting an application.
10. An operation and maintenance plan that specifies the normal operating parameters of the
system or systems. Include, for example, the length and spacing of dose cycles, gallonage of a
dose cycle, and calibration of flow meters or elapsed time meters. The maintenance schedule
should address ALL components to be inspected and maintained, together with procedures for
doing so. For each item, include the frequency for inspecting it and the maintenance procedure.
Plans for collection, storage, and disposal of any sludges generated by the treatment process,
including a characterization of volume and quality.
If available, include the manufacturer's operation and maintenance literature for system components.
Page of 6