Fillable NOTICE OF INTENT TO DISCHARGE MARICOPA COUNTY ENVIRONMENTAL (Maricopa County Telecommunications)

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NOTICE OF INTENT TO DISCHARGE MARICOPA COUNTY ENVIRONMENTAL (Maricopa County Telecommunications)

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MARICOPA COUNTY ENVIRONMENTAL SERVICE DEPARTMENT
WATER & WASTE MANAGEMENT DIVISION
ONSITE WASTEWATER PROGRAM
501 North 44th Street, Suite 200, Phoenix, AZ 85008
Phone: (602) 506-6666 Fax: (602) 506-6925
Email: SepticQuestions@maricopa.gov Website: esd.maricopa.gov
NOTICE OF INTENT TO DISCHARGE
ON-SITE WASTEWATER TREATMENT FACILITY APPLICATION
February 2020 Page 1 of 2
OSWTF Permit #:
Application instructions, general directions, fees, required application submittal items (checklist), and information regarding the license application
process as required by A.R.S. §11-1606, including the permit application process, applicable licensing time frames, county contact information,
website and electronic contact information, and required notices, can be found at http://esd.maricopa.gov/2497/Instructions-Applications. The
applicant is responsible for the information and requirements listed under the application instructions. Application submittals that do not meet the
requirements of the application instructions, including items listed on the submittal checklist, may result in a denial of the application. This application
will expire one year from the date of submittal if a Construction Authorization has not been issued.
1. PROJECT INFORMATION:
DATE SUBMITTED:
REVIEW TYPE:
Construction Authorization Expedited
1
Application Extension
2
Application Transfer
3
Reapplication
4
PROJECT NAME:
PROJECT DESCRIPTION (include expected date of operation, rate, and volume of discharge):
1
Expedited reviews require double the standar
d permit fee. Expedite reviews undergo the first substantive review in half of the time of a standard review and applies only to first substantive review.
2
Application Extensions require half the standard permit fee and extend the expiration date six (6) months from the original expiration date. To apply for an extension, a permit cannot have been issued for the application prior to
granting the extension.
3
Application Transfers require a plan revision fee of $205. Submitted documents must reflect the current ownership of the property. To apply for a transfer, a permit cannot have been issued for the application prior to granting
the transfer.
4
A full permit fee must be paid to reapply for a previously expired permit under the same owner.
2. SITE LOCATION:
Subject Property Address:
City:
State:
Cross Streets:
Subdivision:
Legal Description: Township Range Section
Recorded Deed Number:
Recorded Affidavit of Agreement to Encroach Number:
Latitude:
Longitude:
3. PROPERTY/BUSINESS/PROJECT OWNER:
5
Any changes to this address shall be submitted in writing to MCESD within 15 days of the change. All documents from MCESD will be mailed to
this address unless otherwise noted below. Returned mail will not be forwarded.
ORGANIZATION:
NAME:
Title:
Telephone:
Mobile:
E-mail:
ADDRESS
5
:
City:
State:
ZIP Code:
Country:
4. CONTACT PERSON/AGENT (IF DIFFERENT THAN THE OWNER):
ORGANIZATION:
CONTACT PERSON:
Title:
Telephone:
Mobile:
E-mail:
ADDRESS:
City:
State:
ZIP Code:
Country:
5. ON-SITE INSTALLER:
Same As: Contact Person/Agent
ORGANIZATION:
CONTACT PERSON:
Title:
Telephone:
Mobile:
E-mail:
ADDRESS:
City:
State:
ZIP Code:
ROC License Number:
February 2020 Page 2 of 2 NOID Application
OSWTF Permit #:
6. PERMIT INFORMATION:
APPLICATION TYPE:
6
Alternative/Engineered onsite wastewater treatment facilities must maintain a yearly operating permit with the Department.
New – General Permit 4.02 (conventional OSWTF which consists solely of a septic tank AND disposal field checked below):
Trench - Aggregate Trench – Recycled Concrete Seepage Pit - Aggregate Chamber Leach Bed
New – General Permit 4.03-4.22 (alternative/engineered OSWTF
6
)
Describe proposed treatment and disposal method; indicate all applicable general permit numbers:
Alteration – General Permit 4.02-4.22 (repair or replacement of the OSWTF tank OR disposal field checked below):
Tank Trench – Aggregate Trench – Recycled Concrete Seepage Pit - Aggregate Chamber Leach Bed
Alternative/Engineered Technology
6
Describe:
New – General Permit 4.23 (OSWTF which consists of either conventional or alternative/engineered technology
6
):
Describe proposed treatment and disposal method; indicate all applicable general permit numbers:
WASTEWATER SOURCE:
Single-Family Residence with typical household sewage
Single-Family Residence with typical household sewage and
List all other sources and characteristics of the wastewater
Other Than Single-Family Residence with typical household sewage. Type of Facility:
Other Than Single-Family Residence with other than typical household sewage. Provide the following information:
Type of Facility: Sources and characteristics of the wastewater:
WATER SOURCE: (check one below)
Water Company: Water Company Name:
Holding Tank (hauling water)
Private Well: Well Identification Number:
Shared Well: Shared Well Agreement Recording Number:
7. EXISTING/REQUIRED PERMITS:
List any county, state, or federal environmental permits issued for or needed by the facility, including any individual permit, Groundwater Quality
Protection Permit, or Notice of Disposal that may have previously authorized or related to the discharge (check all that apply below):
Existing OSWTF permits Description/Permit Number:
Other environmental permits required Description/Permit Number:
Building Authority permit Agency: Permit Number:
Flood Control Authority permit Agency: Permit Number:
8. APPLICANT CERTIFICATION:
READ CAREFULLY AND SIGN BELOW, this section is to be completed by the owner or contact person/agent identified on the first page of
the application:
Pursuant to A.R.S. § 41-1009, the Department may enter your premises 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:
, (initials). It is the responsibility of the permit holder to update the Department
if there is a change in contact information.
I , certify that this Notice of Intent to Discharge and all attachments were prepared under the direction or
authorization of the owner or operator of the facility and all information is, to the best of the owner’s or operator’s and my knowledge, true, accurate
and complete. I also certify that the on-site wastewater treatment facility described in this form is or will be, under the direction or authorization of the
owner or operator of the facility, designed, constructed, and operated in accordance with terms and conditions the General Aquifer Protection
Permit(s) (A.A.C. R18-9-E302 through R18-9-E323) and applicable requirements of A.R.S. Title 49, Chapter 2, the Arizona Administrative Code,
Title 18, Chapter 9 regarding Aquifer Protection Permits, and the Maricopa County Environmental Health Code. The owner or operator of the
facility and I am aware that there are significant penalties for submitting false information including permit revocation as well as the
possibility of fine and imprisonment for knowing violations.
Signature:
Owner Agent
FOR INTERNAL USE ONLY
NOID Log in Date: By:
BILLING PURPOSE
AMT PD
RECEIPT #
DATE PD
ACR Completed: By:
(Paperwork Review)
PLAN REVIEW/SITE
SR Pre-Const Completed: By:
(Plan Review)
PLAN REVIEW/SITE
Site Code:
OTHER
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NOTICE OF INTENT TO DISCHARGE MARICOPA COUNTY ENVIRONMENTAL (Maricopa County Telecommunications)

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Completed 6 August 2020

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