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Polk County Public Works (Polk County)

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The Polk County Public Works (Polk County) form is 6 pages long and contains:

  • 4 signatures
  • 52 check-boxes
  • 190 other fields

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File type: PDF

U.S.A. forms for Polk County

BROWSE POLK COUNTY (IA) FORMS

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Polk County Public Works
th
5885 NE 14 Street
Des Moines, IA 50313
Ph: (515) 286-3705
Fa
x:
(515) 286-3437
publicworks@polkcountyiowa.gov
APPLICATION FOR ONSITE WASTEWATER TREATMENT AND DISPOSAL SYSTEM
(OWTS) AND ABANDONMENT
NOTE: A PERCOLATION TEST OR SOIL ANALYSIS MUST BE SUBMITTED WITH THIS APPLICATION. A TREATMENT AND DISPOSAL SYSTEM CANNOT BE INSTALLED
UNTIL A BUILDING PERMIT HAS BEEN APPLIED FOR, IF APPLICABLE.
JOB SITE ADDRESS: _________________________________________________ TOWNSHIP: ____________________________
OWNER: ____________________________________________________________
APPLICANT: ____________________________________________________ PHONE: ____________________________
ADDRESS: __________________________________________________________ CELL: ___________________________
CITY: ________________________ STATE: ________ ZIP CODE: ____________
Email: __________________________________________________________________
(permits and certificate of compliance will be emailed when an email is provided)
SEPTIC CONTRACTOR: _________________________________________________ PHONE: ___________________________
COMPANY: ________________________________________________________ CELL: ____________________________
ADDRESS: _____________________________________________________________
CITY: ________________________ STATE: ________ ZIP CODE: ____________
Email: __________________________________________________________________
(permits and certificate of compliance will be emailed when an email is provided)
DESCRIPTION OF WORK:
NEW ONSITE WASTEWATER TREATMENT
AND DISPOSAL SYSTEM
RESIDENTIAL COMMERCIAL
REPLACE TANK/BOX
REPLACE BOX REPLACE TANK
Please Check
REPLACE OWTS
OTHER
WATER SOURCE:
WELL
NUMBER OF
BEDROOMS
NUMBER OF EMPLOYEES:
MULTI FAMILY DWELLING:
YES
NO
I understand that if the number of bedrooms changes, the Environmental Health Division must be notified before installation of the Treatment and Disposal System commences.
I understand that WORK MUST BE COMPLETED AND INSPECTED WITHIN ONE CALENDAR YEAR from the permit issuance date, or the ONSITE WASTEWATER
TREATMENT AND DISPOSAL SYSTEM PERMIT will be null and void.
I understand all work must be inspected and approved by Polk County prior to concealing any installation.
I hereby acknowledge the above information is correct, and I agree to comply with all ordinances and State and Federal laws regulating activities covered by this permit.
_______________________________________________________________ Date___________________________
Contractor’s Name/Signature
_______________________________________________________________ Date___________________________
Applicant or Owner’s Name/Signature
PERMIT FEES: Residential $196, Commercial $258, Abandonment Fee $62
Office use:
Date: _____/_____/_____ Initials:_______ Cash _____ Check ________ Receipt #: ___________
Permit #______________________
IF ABANDON ONLY - REASON FOR
ABANDONMENT
REPLACE/REPAIR
LATERALS
ABANDONMENT
PUBLIC
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1
ONSITE WASTEWATER TREATMENT SYSTEM SITE DESIGN SPECIFICATIONS
Site Address _________________________________________________________________
New System ____________ Replacement/Repair of existing system ______________
Design Modification __________ Explain__________________________________________
____________________________________________________________________________
Proposed System Description:
Septic Tank Size (in Gallons) _______________
_________ Conventional System
Gravity Flow ________ Pressurized_______
Type of Laterals _________
Length of Laterals _________
_________ At-grade System (licensed engineer design required)
_________ Mound (licensed engineer design required)
_________ Sand Filter Filter Square Footage _________
Gravity Flow _________ Pressurized _________
_________ Single Pass Packed Bed Media Filter (requires a maintenance contract) (Includes
peat filters)
Manufacturer ___________________ Model #____________
_________ Multiple Pass Packed Bed Media Filter (requires maintenance contract)
Manufacturer ___________________ Model #____________
_________Custom System (licensed engineer design required)
_________Experimental System (Subject to Health Officer’s approval and conditions)
Comments: ___________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
POLK COUNTY PUBLIC WORKS
th
5885 NE 14 Street
Des Moines, Iowa 50313
Ph: (515) 286-3705
Fax (515) 286-3437
publicworks@polkcountyiowa.gov
2
CHECKLIST – REQUIRED INFORMATION
_______ _______ _______ Disclosure documents included if system selection is other than
Y N N/A Polk County Board of Health Rules and Regulations Section 3.7.
_______ _______ _______ Has the area where the system is being constructed been
Y N N/A disturbed, cut or filled? If yes, how long since it has been
disturbed, cut or filled?________________________________
_______ _______ _______ Is the system in a floodplain? If so, a floodplain development
Y N N/A application is required.
_______ _______ _______ Boundaries, drainage and utility easements have been included
Y N N/A on the system layout diagram or the percolation test/soil evaluation.
For Discharging Systems:
_______________ A completed copy of the Notice of Intent Application for the NPDES Permit
must be submitted. (See attached)
Distance to Class A Waterway* _________Less than 1 mile (E Coli testing is required)
_________Greater than 1 mile
*Class A waterways in Polk County include: Des Moines River, Walnut Creek, Raccoon River,
Saylorville Lake, Big Creek Lake, Four-Mile Creek, Beaver Creek, Camp Creek, Skunk River, and
any private or public recreational lake exceeding 1 acre in surface area.
_______ _______ _______ Does the system discharge over another’s property? If so, a copy
Y N N/A of the recorded easement must be submitted.
Special Conditions or considerations:________________________________________________
______________________________________________________________________________
______________________________________________________________________________
As a Polk County licensed septic contractor, I hereby affirm that I will conform to the
onsite wastewater treatment and disposal system specifications. Further, I understand that
any variance from this design must be approved by the Administrative Authority before
system installation commences.
_____________________________ ____________________________ _____________
Contractor Signature Print Name Date
Polk County License Number______________________
_______________________________________________________ __________________
Onsite Wastewater System Construction Authorized/Approved Date
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12/2010 cmz DNR Form 542-1541
IOWA DEPARTMENT OF NATURAL RESOURCES ENVIRONMENTAL
SERVICES DIVISION
NOTICE OF INTENT
TO BE COVERED UNDER NPDES GENERAL PERMIT No. 4
“DISCHARGE FROM PRIVATE SEWAGE DISPOSAL SYSTEMS”
(Type or Print)
Current Owner
Address
City
State
Zip
Telephone
( )
Has this private sewage disposal system been previously covered by General Permit #4? Yes No
If yes, please list authorization number:
Section at the bottom of this form
and then proceed to Certification
If no, please provide the following location information:
Location of sewer system
: (Required. If “same as above”, please write “same”)
Street address
City
Zip
Legal description:
(required unless lat./long. available)
¼ of
¼ of
¼ of Sec.
,T
N, R
W E
¼ Section
¼ Section
¼ Section
Section
Township
Range
County (required):
Latitude: (if available)
(Deg./decimal-deg.)
Longitude:
Type of Secondary Treatment:
Sand Filter (buried) Sand Filter (free access) Mechanical/Aerobic Unit
Constructed Wetland Lagoon
Other (describe)
Certification:
For existing private sewage disposal systems, check off the first two items below. For
new installations, check off all three items below:
I certify the above information is true and accurate, to the best of my knowledge.
I agree to abide by all terms and conditions of the DNR NPDES General Permit #4.
I certify that the permitted system will be constructed in conformance with the requirements of IAC 567 -
Chapter 69 and all applicable County requirements.
Signature
Date
A copy of the permit will be mailed to you along with your discharge authorization.
Send completed form to:
NPDES Section
Iowa Department of Natural Resources
502 E 9
th
Street
Des Moines, IA 50319
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5
PRELIMINARY ONSITE WASTEWATER TREATMENT SITE SPECIFICATIONS AND LAYOUT
N
6
FINAL ONSITE WASTEWATER TREATMENT SITE SPECIFICATIONS AND LAYOUT
THIS IS THE APPROVED ONSITE WASTEWATER SYSTEM AS INSTALLED.
INSPECTOR________________________________DATE_________
LICENSED CONTRACTOR (OR HIS DESIGNEE)____________________________DATE_______
N
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Polk County Public Works (Polk County)

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Completed 14 February 2021

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