Fillable Approval To Construct COVER / TRANSMITTAL PAGE (Maricopa County Telecommunications)

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Approval To Construct COVER / TRANSMITTAL PAGE (Maricopa County Telecommunications)

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Revised October 2018 - Fillable
Maricopa County
Environmental Services
Approval To Construct
(ATC)
Mailing and Delivery Address:
Maricopa County Environmental Services Department
Subdivision Infrastructure and Planning Program
501 N. 44
th
St., Suite 200
Phoenix, AZ 85008
COVER / TRANSMITTAL PAGE
This packet is for submitting Approval TO Construct applications for these projects:
- Water Line Extension - Sewer Line Extension - Storage Tank - Pressure Tank
- Water Booster Station - Sewer Lift Station - Well - Chlorination
- Reuse Lines - Master Plans - Geological Reports - Waiver Request
Use this Cover/Transmittal Page for all projects EXCEPT Geological Reports.
For Geological Reports, use the Geological Report Cover Page (next page).
Detailed instructions for completing this packet are included. Our experience shows that most questions are already
answered by the attached instructions or the form itself. Each transmittal page has a check list of ALL the required
information for a complete submittal. Incomplete submittals will be returned to you. Also included is a fee list so that
you can calculate the fees.
Project Name:
(PLEASE PRINT CLEARLY)
Contact Person:
Title
E-mail address of contact person
Company Name:
Phone number: Ext: Fax Number:
City: State: Zip Code:
Application Check List for Approval to Construct
Cover/Transmittal Page for MCESD Projects – this page (or next for Geological)
ATC Fee’s – list attached
Approval to Construct application pages 1 of 3, 2 of 3 and 3 of 3 (attached)
Full size set of plans with every page sealed and signed by engineer. (1 set only)
Water Design Report-water projects only (must be sealed & signed by a registered engineer)
Sewer Design Report-sewer projects only (must be sealed & signed by a registered engineer)
Sewer Capacity Letter (must be issued by the sewer utility provider, NOT the engineer)
If you are submitting for a sewer line project, it will not be accepted without a sewer capacity letter. Date
and signature cannot be more than one year old
.
Sewer Capacity Letter - a statement, signed by the owner or operator of the sewage treatment facility and/or down
stream collection system, affirming compliance in accordance with R18-9-E301.C.
Operation and Maintenance Plan – there must be verification of an O&M Plan. Submittal of the O&M Plan will be
upon request.
Any questions contact Cindy Furze at 602-506-1058 or CFurze@Maricopa.gov
*** The Department reserves the right to request any other information ***
Visit our web page at www.maricopa.gov/EnvSvc/WaterWaste/Subdivisions/Subdivisions.aspx
Revised October 2018 - Fillable
Maricopa County
Environmental Services
Approval To Construct
(ATC)
Mailing and Delivery Address:
Maricopa County Environmental Services Department
Subdivision Infrastructure and Planning Program
501 N. 44
th
St., Suite 200
Phoenix, AZ 85008
COVER PAGE / TRANSMITTAL PAGE FOR GEOLOGICAL REPORT
USE THIS PAGE
ONLY
IF APPLYING FOR A CERTIFICATE OF GEOLOGICAL REPORT FOR ON-
SITE SEWAGE DISPOSAL FOR SEPTIC SUBDIVISIONS
Detailed instructions for completing this packet are included. Our experience shows that most questions are already
answered by the attached instructions or the form itself. Each transmittal page has a check list of ALL the required
information for a complete submittal. Incomplete submittals will be returned to you. Also included is a fee list so that
you can calculate the fees.
Project Name:
Contact Person:
Title
E-mail address of contact person
Company Name:
Phone number: Ext: Fax Number:
Address:
City: State:
Zip
Code:
Application Check List for On-Site Sewage Disposal/Septic Subdivision submittal
Approval To Construct Application
Check the box Soils on application
Cover Page
This cover page must be submitted with the Approval To Construct
application.
Soils Test Plan
The plan must include the following
• location on the plat where the soils testing will be performed
(percolation tests and soil borings)
• the method of testing
• person/firm performing tests
• depth to seasonal high groundwater level
• site specific geology and topography
• list of information that will be included in the final soils testing
report (field notes, soils boring logs, etc.)
Percolation test methodology
Must be specified and comply with the Arizona Administration Code
R18-9-A310.E or F, depending on the proposed method of effluent
disposal. (No mere reference to AAC Code)
All Soil Borings must be a minimum of 50 feet
in depth
Unless disposal pits deeper then 50 feet are proposed.
Statement on the plans:
This will allow coordination for a site visit during the field activities.
“At least five (5) working days notice will be provided to the reviewing
Senior Civil Engineer for MCESD”.
Any questions contact Cindy Furze at 602-506-1058 or CFurze@Maricopa.gov ***
The Department reserves the right to request any other information ***
Visit our web page at www.maricopa.gov/EnvSvc/WaterWaste/Subdivisions/Subdivisions.aspx
Revised October 2018 - Fillable
Maricopa County
Environmental Services Department
Water and Waste Management Division
501 N 44
th
St., Suite 200
Phoenix, Arizona 85008
Phone: (602) 506-1058
www.maricopa.gov/envsvc
PERMIT APPLICATION PROCESS NOTICE
Subdivision Infrastructure and Planning Program
1) Steps required to obtain an Approval to Construct/Approval of Construction for Water Systems,
Sewer Systems and Reuse Water Lines are as follows:
i) Submission of the complete application for Approval To Construct along with all relative
items in the application check list on the Cover/Transmittal Page of the application. When
the review is complete, an Approval To Construct certificate will be issued to allow
construction of the system to commence.
ii) Construction of the project.
iii) Submission of the complete application for Approval of Construction along with all relative
items in the application checklist on the Cover Page of the application. When the review and
approval of the submitted documentation is complete, an Approval Of Constructio
n
cer
tificate is issued. The system can then be put into service.
2) T
he Department will approve or deny the application in the number of business days listed below or
less, excluding any days the application is returned to the applicant for additional information. This
overall licensing timeframe is set by the Arizona Department of Environmental Quality (ADEQ) as
required by A.R.S. §11-1605 and is part of the Delegation agreement between ADEQ and Maricop
a
c
ounty.
Permit
Overall Timeframe
(Business Days)
Wastewater System
300 Services or less (Gravity/Force Main)
95
More than 300 Services (Gravity)
136
Sewer Lift Station
95
Wastewater Master Plan or Amendment
83
Wastewater Line Waiver
53
Drinking Water System
Standard - Public Water Supply Distribution Line
53
Complex
83
Chlorination Plan
53
Booster Pump Station
53
Storage Tank / Pressure Tank
53
Drinking Water Master Plan or Amendment
53
Drinking Water Line Waiver
53
Reclaimed Water System
Standard
95
Complex
NA
3) Department contact information regarding your application
i) Telephone: 602-506-1058
ii) E-mail: subdivision@mail.maricopa.gov
iii) Website: www.maricopa.gov/EnvSvc/WaterWaste
Y
ou may request a clarification from the Department of its interpretation or application of a statute,
ordinance, regulation, delegation agreement or authorized substantive policy statement as provided in
A.R.S. §11-1609. Contact us by e-mail or telephone, or in person or mail at the address listed at the top of
the page, marked attention Subdivision Infrastructure & Planning Program.
Revised October 2018 - Fillable
Maricopa County
Environmental Services Department
Water and Waste Management Division
501 N 44
th
St., Suite 200
Phoenix, Arizona 85008
Phone: (602) 506-1058
www.maricopa.gov/envsvc
PERMIT APPLICATION PROCESS NOTICE
Subdivision Infrastructure and Planning Program
1) Steps required to obtain an Approval of Soils / Hydrology Report are as follows:
i. Submission of the complete application for Approval of Soils / Hydrology
Report along with all relative items in the application check list on the
Cover/Transmittal Page of the application. When the review is complete, an
Approval of Soils / Hydrology Report certificate will be issued to allow
construction of the system to commence.
ii. Construction of the project.
2) T
he Department will approve or deny the application in the number of business days listed below or
less, excluding any days the application is returned to the applicant for additional information. This
overall licensing timeframe is set by the Arizona Department of Environmental Quality (ADEQ) as
required by A.R.S. §11-1605 and is part of the Delegation agreement between ADEQ and Maricop
a
county.
Permit
Overall Timeframe (Business Days)
Soils / Hydrology Report
Standard
67
3) Department contact information regarding your application
i. Telephone: 602-506-1058
ii. E-mail: subdivision@mail.maricopa.gov
iii. Website: www.maricopa.gov/EnvSvc/WaterWaste
Y
ou may request a clarification from the Department of its interpretation or application of a statute,
ordinance, regulation, delegation agreement or authorized substantive policy statement as provided in
A.R.S. §11-1609. Contact us by e-mail or telephone, or in person or mail at the address listed at the top of
the page, marked attention Subdivision Infrastructure & Planning Program.
Revised October 2018 - Fillable
Maricopa County
Environmental Services
Approval To Construct
Fee List
Fees for
Approval To Construct (ATC) and
Soils Reports
Make Checks Payable to MCESD
A $35.00 fee for all returned checks
Double The Fee For Expedited Review
ATC FEES
Public water supply system
Sewer collection system
$600.
150 or less connections
Gravity Sewer only, including manholes
$1200.
151 to 300 connections
$500.
Serving 50 connections or less
$1800.
301 to 450 connections
$1000.
Serving 51 to 300 connections
$2400.
451 to 600 connections
$1500.
Serving 301 or more connections
$3000.
601 to 750 connections
Force Mains + Gravity Sewer
$3600.
751 to 900 connections
$800.
Serving 50 connections or less
(Every 150 connections add $600.)
$1300.
Serving 51 to 300 connections
$1800.
Serving 301 or more connections
Other Components
$675.
Storage Tank (each)
$600.
Sewer Lift Station
$500.
Master Plans - Per Component
$675.
Well (each)
$250.
Reuse lines
(Water/Sewer)
$675.
Pressure Tank (each)
$150.
Chlorination
$150.
Waiver (each)
$675.
Booster Station
Any Fee Questions Contact MCESD
** “An approval of plans and specifications can be renewed for one year if an application for renewal is submitted within 180 days of
expiration. A fee equal to one-half (1/2) of the flat fee or initial plan review fee is paid. The approval will be effective for one year from the
date of expiration”. MCESD Ch. 1, Reg. 4f. (Check with MCESD if questions.)
Geological (Soils) Report Fees
$525.
50 lots or less
$1050.
51 to 100 lots
$1575.
101 to 150 lots
$2100.
151 to 200 lots
(Every 50 lots add $525.)
Fees
Regular Fees
Expedited Fees
Break down fees (fees for multiple components on the same project can be put on one (1) check)
Type of component
(.i.e.: water line, sewer line, etc)
Regular Fee per
component
Expedited Fee per
component
Total Fee per component
TOTAL FEE
*** The Department reserves the right to request any other information ***
Revised October 2018 - Fillable
Maricopa County
Environmental Services
Approval To Construct
Application Instructions
APPLICANT – You only need to complete those portions of the form that apply to your
project. If submitting a water line, you do not need to provide information on the sewer
system and vice versa.
For Soils, Master Plans and Waiver Requests only – on page 1 of 3 fill out #1 only and page 3 of 3 - #4,
5, 6.
Page 1 of 3
1.
Project Name –
must be the same as on the engineered plans. This name will appear on the ATC certificate.
Project Address – physical location of project.
City, AZ and Zip Code – of actual location of project.
Section, Township, Range –
information can be located in the Phoenix Metropolitan Street Atlas or on the plans.
Project Description – what type of review you are requesting from our department.
• You will receive an individual certificate for each component.
(Example: water line extension, lift station, well site and/or any other component)
2. System information required:
Water / Well information – Provide rest of numbers for PWS for the Public Water System and/or the DWR for the well as the
case may be.
Sewage Information –
Sewage Collection System Owner – name of sewage collection system owner, providing sewer
service to the project.
Sewage Treatment Facility Owner – name of owner of treatment facility, may be different from the
collection system owner.
3. Quantity:
Number of water and sewer connections – number of service connections on the project that we are to review.
Water and Sewer Linear Feet and Size – these totals are included on the certificate our Department issues.
Reuse Linear Feet and Size – these totals are included on the certificate our Department issues.
Page 2 of 3 – ONLY NECESSARY IF SUBMITTAL IS FOR WATERLINE OR WATER COMPONENT
Public Water Supply number (PWS) Signature Form – if this form is not signed, your project will be denied. This agreement
MUST be signed by the Public Water System Representative NOT the Engineer or Project owner.
PWS # - public water system number from the water supply provider.
Project Name –
the name of the project
Project Address –
physical location of project.
City, Zip Code –
location of project
Public Water Supply Provider –
name of public water supply system that will be providing water service to the project.
Page 3 of 3
4. Name of Registered Engineer – registered engineer who is the contact person for project. (Please Print Clearly)
Phone Number, Ext and Fax –
phone number, extension, and fax number of registered engineer working on the project.
E-mail Address – e-mail address for the registered engineer working on the project.
Name of Engineering Firm as Registered with the AZ Board of Technical Registration -
a registered engineering
firm that employees the project engineer.
Mailing Address, City, State and Zip Code - mailing address of registered engineering firm.
5. Project Owner/Responsible Party - MUST be a person with fiduciary responsibilities associated with the Project or Company.
Job Title - examples: Project Owner, President or Vice President of Corporation/Home Owners Association, Manager.
E-m
ail address –
e-mail address for the project owner/responsible party.
Company Name -
the name of Company who owns the Project.
Mailing Address, City, State, Zip Code -
location of Project Owner, will be put on certificate.
Phone Number, Ext and Fax -
project owner phone, extension and fax number.
6. Authorization–
Only the named Project Owner/Responsible Party can sign for the Project Owner/Responsible Party unless there
is a letter of authorization.
Revised October 2018 - Fillable
Environmental Services Department
501 N. 44
th
St., Suite 200
Phoenix, AZ 85008
Division of Water and Waste Management
Subdivision Infrastructure & Planning
Phone (602) 506-1058
Application for Approval to Construct (ATC) and/or
Provisional Verification of General Permit Conformance **
for
Water/Wastewater Facilities
Page 1 of 3
On-Site
Off-Site
Use separate applications for On-Site and Off-Site if submitting both.
Waterline
Gravity Sewer
Storage Tank
Pressure Tank
Reuse
Well
Force Main
Booster Station
Chlorination
Lift Station
Reissue
Master Plan
Soils
Other:
"On-site, Off-site, Master Plan, and Soils projects each require separate applications if submitted together."
1. Project Name:
(Physical location of Project)
Project Address
,
City
, AZ
Zip Code
Section
Township
Range
Project Description:
2. System information required
Water / Well Info
Public Water Supply Provider (PWS) 0407
Wells Only:
DWR# 55-
Sewage Info
Sewage Collection System Name
Sewage Treatment Facility Name (if different)
3. Quantity:
Number of water connections
Number of sewer connections
Water Line
Sewer Line
Reuse Line
L.F.
Size
in.
L.F.
Size
in.
L.F.
Size
in.
L.F.
Size
in.
L.F.
Size
in.
L.F.
Size
in.
L.F.
Size
in.
L.F.
Size
in.
L.F.
Size
in.
L.F.
Size
in.
L.F.
Size
in.
L.F.
Size
in.
L.F.
Size
in.
L.F.
Size
in.
L.F.
Size
in.
L.F.
Size
in.
L.F.
Size
in.
L.F.
Size
in.
L.F.
Size
in.
L.F.
Size
in.
L.F.
Size
in.
L.F.
Size
in.
L.F.
Size
in.
L.F.
Size
in.
Total Water L.F.
Total Sewer L.F.
Total Reuse L.F.
** This application constitutes the Notice of Intent to Discharge referenced by R18-9-A301.B.
"NO APPLICATION WILL BE ACCEPTED UNLESS FULLY COMPLETED "
Revised October 2018 - Fillable
Environmental Services Department
501 N. 44
th
St., Suite 200
Phoenix, AZ 85008
Division of Water and Waste Management
Subdivision Infrastructure & Planning
(602) 506-1058
Application for Approval to Construct (ATC) and/or
Provisional Verification of General Permit Conformance **
For Water/Wastewater Facilities
Public Water Supply Number (PWS) Signature Form
Page 2 of 3
PWS number
0407
(Public Water Supply number)
WATER SERVICE AGREEMENT - An unconditional agreement which is effective this date has been
made between the owners of:
Project Name
(Physical location of Project)
Project Address
,
City , AZ
Zip Code
,
and the
(Public Water Supply Provider “PWS”)
The undersigned hereby agrees to provide water to the above project with the Public Water Supply
(PWS) number and they agree that the PWS is in compliance and on file with Maricopa County
Environmental Services Department (MCESD).
Date
Print Name clearly
Job Title
Address
City
Signature
Signature must not be over one (1) year old.
This agreement MUST be signed by the Public Water System
Representative NOT the Engineer or Project owner.
Fai
lure to provide a Public Water Supply (PWS) number that is in
compliance will result in immediate rejection of your project.
**
* The Department reserves the right to request any other information ***
Revised October 2018 - Fillable
Environmental Services Department
501 N. 44 St., Suite 200
Phoenix, AZ 85008
Division of Water and Waste Management
Subdivision Infrastructure & Planning Phone
(602) 506-1058
Application for Approval to Construct and/or
** Provisional Verification of General Permit Conformance **
For Water/Wastewater Facilities
Page 3 of 3
4. Name of Registered Engineer Working on Project:
Must be Registered with the Arizona Board of Technical Registration. Number:
Phone Number
Ext
Fax
E-mail address
Name of Engineer's Firm as Registered With
The AZ Board of Technical Registration:
Mailing Address
City
State
Zip Code
(Please print legibly)
(The information provided will be used on the ATC Certificate)
5. PROJECT OWNER NAME:
Can be Individual or Company
Responsible Party
Job Title
Must be a Person with fiduciary responsibilities associated directly with the project ownership
Mailing Address
City
State
Zip Code
Phone Number
Ext
Fax Number
E-mail address
6. Authorization
The Project Owner/Responsible Party hereby authorizes the review of project plans as described for approval to construct and/or
provisional verification of conformance under General Aquifer Protection Permit 4.01.
_______________________________/___________________________ __________________
Signature of Project Owner/Responsible Party / Please print name Date (not more than 1 year old)
Please complete and attach Letter of Authorization if Project Owner is not signing above.
Pursuant to A.R.S. § 41-1009, the Department may enter your establishment to conduct inspections. You have the right to receive a copy of the
Department’s inspection report at the time of the inspection, within thirty (30) days after the inspection, or as otherwise provided by federal law.
By initialing below, I agree that the Department may send me a copy of its inspection report by e-mail to the following email address:
______________________________________________________________or by facsimile transmission to the following fax number:
________________________________ (Fax Number). ___________ (Initials).
** It is the responsibility of the permit holder to update the Department if there is a change in contact information. **
"NO APPLICATION WILL BE ACCEPTED UNLESS FULLY COMPLETED"
Department use only
Waterline
Gravity Sewer
Storage Tank
Well
Force Main
Booster Station
Reissue
Master Plan
Other:
Reuse
Pressure Tank
Lift Station
Chlorination
Check number (s)
Amount Paid
Revised October 2018 - Fillable
Maricopa County Environmental Services
Subdivision Infrastructure & Planning Program
LETTER OF AUTHORIZATION
Complete this form
ONLY
if the Project Owner/Responsible
Party is not signing the application
This form is effective for one (1) year from date of signature.
Please Print Clearly
Date:
I hereby authorize
, of
firm to file
(Engineering Firm / Organization)
and sign this application and act on my behalf for project(s) name(s) listed:
Project Owner /
Responsible Party Name /
Title:
/
NAME / TITLE
Signature of Project Owner /
Responsible Party of Fiduciary Responsibility
*** MANDATORY ***
NOTES: - Project Owner’s / Responsible Party’s information must be on application for use on the certificate.
- Engineer cannot sign this form as Project Owner / Responsible Party
Department Use Only
MCESD number (s):
*** The Department reserves the right to request any other information ***
Visit our web page at www.maricopa.gov/EnvSvc/WaterWaste/Subdivisions/Subdivisions.aspx
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Approval To Construct COVER TRANSMITTAL PAGE (Maricopa County Telecommunications)

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Completed 6 August 2020

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