Fillable ADAMS CANYON SEWER SYSTEM CONNECTION (ACS) PERMIT APPLICATION (Teton County Wyoming Government)

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ADAMS CANYON SEWER SYSTEM CONNECTION (ACS) PERMIT APPLICATION (Teton County Wyoming Government)

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Page 1 of 3
Adams Canyon Sewer System Connection Application
Resolution 2016-003 / Effective January 19, 2016
ADAMS CANYON SEWER SYSTEM CONNECTION (ACS)
PERMIT APPLICATION
Planning & Development Department
Building Division
200 S. Willow Street
PO Bo 1727
Jackson, WY 83001
ph: (307) 733-7030 BUILDING DEPT.
ph. (307) 733-3317 ENGINEERING DEPT.
www.tetonwyo.org
Instructions: Please complete all sections of this application. If there are any questions, please call the Engineering
Department office at (307.733.3317)
Please deliver the following to the County Building Department:
1. This completed Connection Permit Application.
2. 3 sets of site plans and floor plans (11” X 17”). (1 set for Town of Jackson, 1 set for Teton County, 1 set for return to
applicant). These plans shall include mechanical water and sewer plans showing the location and type of all service
lines, plumbing fixtures, water meters, and backwater valves, all grease traps, grease or sand/oil interceptors, a
nd
pre-treatment facilities (if applicable). Floor plans for all levels shall be included. PLEASE INCLUDE ANY APPLICABLE
TOWN OF JACKSON STANDARD DETAILS AS APPROPRIATE FOR THE CONNECTION. All Work must be done i
n
accordance with the Town of Jackson standards and Teton County Adams Canyon Sewer Rules and Regulations
(Resolution 2016-003).
3. A nonrefundable Application Fee of One Hundred ($100.00) Dollars.
Please comply with the following coordination process for permit processing:
1. Submit to the Teton County Building Department a completed Adams Canyon Sewer Connection Permit Application
and a non-refundable application fee of One Hundred ($100.00) Dollars. If deemed complete, the permit
paperwork will be forwarded to the Town of Jackson Engineering Department for their review.
2. All sewer use must be metered and all meters must be supplied by the Town of Jackson. If you need a meter, please
complete a Water Meter Purchase Agreement, available from the Town of Jackson.
3. When contacted by the Town of Jackson Engineering Department, sign the “Wastewater Treatment Facilities
Connection and Use Agreement”, pay the Town of Jackson Wastewater Capacity Fee, pick up approved permit
paperwork and receipt of payment. The Town of Jackson shall email confirmation of calculated Equivalent
Residential Units (ERUs), and confirmation of all permits approved and fees paid to Teton County Engineering and
Building Department staff.
4. When contacted by the Teton County Building Department, pay the Teton County Adams Canyon Sewer Syst
em
C
onnection and Use Permit fees and pick up the approved permit.
5. Construction inspection is required by Teton County Engineering. Call Gabe Klamer 732-8581 to schedule.
OFFICE USE ONLY
Fees Paid ______________
C
heck No
. ______________ Credit Card ______________ Cash ___________
ACS ____________ BDC/BDR
Page 2 of 3
Adams Canyon Sewer System Connection Application
Resolution 2016-003 / Effective January 19, 2016
OWNER INFORMATION
A c
opy of the Warranty Deed or Contract of Sale must accompany this application.
Printed Name:
Billing Address:
(City) (State) (Zip)
Phone #: Email:
APPLICANT INFORMATION (If other than owner)
Printed Name:
Mailing Address:
(City) (State) (Zip)
Phone #:
Email:
PROJECT INFORMATION
Description:
Physical Address: Lot #:
PIN
Use (Check all uses): ___ Residential ___ Non-Residential
(N
umber of units) _____ Residential Units ____ Non-Residential Units
(
Sq. Ft. each unit) _____ Sq. Ft. per Unit ____ Sq. Ft. per Unit
Explain Non-Residential Use Type
Use additional space for more units or details:
Type (check one): New construction Remodel Existing Structure
Contractor’s Name: Phone #:
Plumber’s Name: Phone #:
Page 3 of 3
Adams Canyon Sewer System Connection Application
Resolution 2016-003 / Effective January 19, 2016
CONNECTION AND USER FEE CALCULATION
The Adams Canyon Sewer Connection Fee is Five Hundred Eighty-Two ($582.00) Dollars per Equivalent Residential
Unit (ERU). An ERU is defined as residential unit: house, condominium w/laundry, townhouse, or apartment with
two or more bedrooms. The number of ERUs for determining the Adams Canyon Sewer Connection fee is
determined by dividing the total Town of Jackson Wastewater Capacity Fees by the Wastewater Capacity Fee for a
residential unit as specified in the Jackson Municipal Code, Section 13.08.020.
The Annual User Fee is the user’s pro-rated share of the operation, maintenance and repair or replacement of the
Adams Canyon Sewer System. The annual fee is One Hundred Dollars ($100.00) per Equivalent Residential Unit
(ERU). THE FIRST ANNUAL FEE IS DUE AND PAYABLE UPON PERMIT ISSUANCE. THE ANNUAL FEE IS NOT PRO-RATED
AND IS PAYABLE IN FULL FOR THE FIRST YEAR WHEN CONNECTION IS MADE. THE ANNUAL FEE SHALL BECOME DUE
AND PAYABLE AT THE BEGINNING OF EACH YEARLY CYCLE AND WILL BE BILLED ANNUALLY.
Please note, a separate monthly user fee will be collected by the Town of Jackson based on metered sewer use.
CERTIFICATION
Under Penalty of perjury, I hereby certify that I have read this application and state that the information herein is
correct. I agree to comply with all applicable County Regulations and State laws related to this application and
hereby authorize representatives of the Town of Jackson and Teton County to enter upon the above mentioned
property for inspection purposes.
In signing this application, I acknowledge that the County’s acceptance of this application and related fees does not
constitute approval of the permit. I agree to not commence any work related to this application prior to approval
by the appropriate Town of Jackson and Teton County agencies and payment of any fees due.
Signature: Date:
Printed Name:
THE FOLLOWING APPROVALS ARE REQUIRED (For Teton County use only)
Pre-backfill Inspection (Bedding, Connection Inspection)
Approver’s Printed Name: Date:
Approver’s Signature:
Post-backfill Inspection (Pressure Testing, cleanouts to standards)
Approver’s Printed Name: Date:
Approver’s Signature:
APPLICANT SHALL PROVIDE AS-BUILT DRAWINGS IF CONSTRUCTION DEEMS APPLICATION DRAWINGS
INACCURATE.
Inspector Comments:
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ADAMS CANYON SEWER SYSTEM CONNECTION (ACS) PERMIT APPLICATION (Teton County Wyoming Government)

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Completed 18 July 2020

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