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Sanitary Facilities for Subdivision COVER / TRANSMITTAL PAGE (Maricopa County Telecommunications)

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Revised October 2018 - Fillable
Maricopa County
Environmental Services
Sanitary Facilities for Subdivision
(aka Health Cert) Packet
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 Sanitary Facilities for Subdivision (aka Health Cert) applications.
Submittals accepted after proof of water/wastewater approval.
Select the type of Project by checking one
Sanitary Facility for Subdivision for Single Family Residence
(aka Health cert for Public Report)
Re-issue Certificate (Any Changes)
Condominium / Townhouse
(aka Health cert for Public Report)
Condominium Conversion SEE NEXT PAGE
(aka Health cert for Public Report)
Use this Cover/Transmittal Page for all projects EXCEPT Condominium Conversions.
For Condominium Conversions, use the Condominium Conversions Cover Page (next page).
Detailed instructions for completing this packet are included. The attached instructions or the form itself already
answers most questions. Each transmittal page has a checklist 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
Company Name:
Phone number: Ext: Fax Number:
Address:
City: State: Zip Code:
Application Checklist for Sanitary Facilities for Subdivision
Cover Page for MCESD Projects – this page (or next page for Condo Conversions)
We need to know on the cover page what you are requesting from us, even if you have spoken to one of us.
Sanitary Facilities for Subdivision application (3 pages attached)
Subdivision Fees (attached)
-
Expedited
Yes
No
Amount
(Make Checks Payable To MCESD)
Copy of the Final Recorded Plat (please fold to approximately 8 1/2 X 11 size)
Copy of the Recorded CC&R's (only for Condominium’s)
** If your Subdivision is in the City of Phoenix, you must also have the items listed below. **
Signed copy of the water and sewer plans that were approved/signed by the City of Phoenix (please fold to approximately 8 1/2 X 11 size)
Copy of the Approval to Construct Certificate (ATC) for water and sewer issued by City of Phoenix
If subdivision uses septic systems, see On Site Sewage Disposal/Septic requirements. See ATC Packet
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
Sanitary Facilities for Subdivision
(aka Health Cert) Packet
Mailing Address & Delivery Address:
Maricopa County Environmental Services Department
Subdivision Infrastructure and Planning Program
501 N. 44
th
St., Suite 200
Phoenix, AZ 85004-1940
COVER / TRANSMITTAL PAGE FOR CONDOMINIUM CONVERSIONS
USE THIS PAGE ONLY IF SUBMITTING A CONDOMINIUM CONVERSION PROJECT
Detailed instructions for completing this packet are included. The attached instructions or the form itself already
answers most questions. Each transmittal page has a checklist 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
Company Name
Phone number: Ext: Fax Number:
Address:
City: State: Zip Code:
Application Checklist for Sanitary Facilities for Subdivision
Cover Page for MCESD Projects – this page
Sanitary Facilities for Subdivision application (3 pages attached)
Subdivision Fees (attached)
-
Expedited
Yes
No
Amount
(Make Checks Payable To MCESD)
Copy of the Final Recorded Plat (please fold to approximately 8 1/2 X 11 size)
Copy of the Recorded CC&R's
Accurate As-Built plans, sealed and signed (please fold to approximately 8 1/2 X 11 size)
Photos as a separate exhibit
Copy of current Water/Sewer/Refuse bill **City of Phoenix must sign page 3 (Refuse Agreements) if
project is in Phoenix**
Complete list of unit numbers
Any questions contact Cindy Furze at 602-506-1058 or CFurze@mail.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
Requirements for a Condominium
Conversion
Explanation of Requirements for a Condominium Conversion
These requirements are in addition to the items needed for a regular
submittal of Sanitary Facility for Subdivision.
1) Com
mon under-ground water lines and sewer line plans as a separate exhibit, showing water and sewer lines, clean outs
and water valves, and other features in the common elements.
• One set of accurate sealed and signed as-built plans. (A registered Land Surveyor or a registered Engineer can
s
eal and sign). “A copy of the final as-built plans must be provided to the HOA by the person working on th
e
project” will be a stipulation of the Health Certificate.
(MCESD will not provide the copy to the HOA)
2) Identify on the as-built plans ALL of the water shut-off valves, backflow preventers, clean outs, etc. for the project and
number them with a unique number. Take digital photographs of each one of them and put them on a separate sheet(s)
with their identification number and/or provide them on CD disk with label. Include the backflow preventers for any autofill
lines for pools/spas/fountain. Include a few representative photos of the exterior hose bibs with the vacuum breakers.
3) If the apartments/condominiums are still being lived in;
• A copy of a current Water/Sewer/Refuse bill can be attached, replacing pages 2 & 3 of our Approval of Sanitary
Facilities for Subdivision application.
• Page 1 of our “Application for Approval of Sanitary Facilities for Subdivision” must be attached.
** If the project is located in Phoenix, the City of Phoenix must sign the Refuse agreements **
NO EXCEPTIONS
4) One (1) copy of the CC&R’s that reflects ownership, operator and maintenance for common water and sewer lines.
5) One (1) copy of a full size Final Recorded Plat. If the plat is not recorded, we can NOT accept your project.
6) We need a complete list of the unit numbers. If there are a large number of units, you can include a copy of the list with the
appl
ication packet.
7) Fees are figured by actual number of units. Fee List follows.
Revised June 2012 - 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
P
ERMIT APPLICATION PROCESS NOTICE
Subdivision Infrastructure and Planning Program
1) Steps required to obtain a Sanitary Facilities for Subdivision (aka Health Cert)/Approval of a Mobile Home
Park are as follows:
i) Submission of the complete application for Sanitary Facilities for Subdivision/Approval of a Mobil
e
H
ome Park along with all relative items in the application check list on the Cover/Transmittal Page of
the application.
ii) The submittal will be reviewed/additional information may be requested.
iii) The Approval of Sanitary Facilities for Subdivision/Mobile Home Park will be issued.
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. §11-160
5
an
d is part of the Delegation agreement between ADEQ and Maricopa county.
Permit
Overall Timeframe (Business Days)
Subdivision
Individual water/sewer facilities
67
Community water/sewer facilities
58
Mobile Home Park
Onsite water/sewer facilities
67
Offsite water/sewer facilities
58
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
4) 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
.
C
ontact 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 June 2012 - Fillable
Maricopa County Environmental Services
Subdivision Instructions
& Fees
Subdivision Application Instructions
1. Project Description:
- Name of Subdivision/Condominium - must match the name on the Final Recorded Plat.
- Individual Unit/Lot - select the type of project. (example: Single Family or Condominium/Townhome)
- With # of units/lots - enter the total number of units/lots. (example: 100)
- Associated lot numbers - write the lot/unit numbers (example: 101-201,101-103,105,107,109 etc). Group numbers if continuous as shown.
Attach list if necessary / not enough room in space provided.
- Project Address – physical location of project.
- City, Zip Code – location of project
- North, South, East and West - enter the street names that surround the actual project location.
- Section, Township, Range - information can be located in the Phoenix Metropolitan Street Atlas.
- RECORDER’S INFORMATION The final plat must be recorded to submit this application. – Date; Book; Page; Recorder’s Number
- Any lots that require grinder pumps - enter the lot number that the pump will be located on, if any.
2. Approved Sanitary Facilities: (MCESD numbers do not apply to the City of Phoenix projects)
- Approved MCESD Water number - the number assigned by MCESD on the Water Approval to Construct certificate.
- PWS Number - public water system number from the water supply provider.
- Water Supply Provider - the water system listed and agreement signed on page 2.
- Approved MCESD Sewer number - the number assigned by MCESD on the Sewer Approval to Construct certificate.
- Public Sewer System - the sewer system listed and agreement signed on page 2.
- On Lot Sewage Disposal/Septic – Check box if there is septic for this project. Include the approved MCESD number assigned on the
Certificate of Approval of a Geological Report For Subdivisions.
- Refuse Collection Agency - the refuse collection agency listed and agreement signed on page 3.
- Approved Refuse Disposal Site - the disposal site listed and agreement signed on page 3.
3. Project Owner (RESPONSIBLE PARTY):
- Name - MUST be a person with fiduciary responsibilities associated with the Project Company.
- Job Title - examples: Owner, President or Vice President of Corporation/Home Owner Association, Manager.
- Project Company Name - examples: Project Owner, Corporation, Home Owner Association.
- Mailing Address, City, State, Zip Code - location of Project Owner/Responsible Party, will be put on the certificate.
- Phone number, fax – project owner’s phone and fax number.
- Engineering Firm – Engineering Firm that worked on the project or is still working on the project.
Signature Line - The Project Owner / Responsible Party must sign. The engineer can not sign unless there is a letter of authorization, which must
be attached.
Pages 2 and 3:
Water, Sewer, Refuse Service Agreement and Refuse Disposal Agreements -
Must be signed by authorized person of agency providing the service, not to be signed by Project Owner or engineer; can not be reused for
other projects.
* City of Phoenix projects must have signatures from City of Phoenix on page 3 – NO EXCEPTIONS. *
Fees for
Sanitary Facility for Subdivision
Make check payable to MCESD
Check or cash payments only
$450.
150 lots or less
$900.
151 to 300 lots
$1350.
301 to 450 lots
$1800.
451 to 600 lots
For every 150 lots add $450.
$200.
Transfer Ownership on Previously
Approved Subdivision certificate
Double the fee for expedited review
$35.00 fee for all returned checks
*** The Department reserves the right to request any other information ***
Revised June 2012 - Fillable
ENVIRONMENTAL SERVICES DEPARTMENT
501 N. 44
th
St., Suite 200
Phoenix, AZ 85008
Division of Water and Waste Management
Subdivision Infrastructure & Planning Program
Phone (602) 506-1058
Application for Approval of Sanitary Facilities for Subdivision
Page 1 of 3
1.
PROJECT DESCRIPTION:
Name of Subdivision/Condominium
is an individual unit/lot ( Single Family Condominium/Townhome) subdivision
with #
units/lots, with associated lot numbers
(Attach list if not enough room)
Physical location of Subdivision/Condominium
Project Address
,
City
,
Zip Code
,
Vicinity Location
North of
,
South of
,
East of
,
and West of
in
Section
Township
Range
Recorder’s Information on Final Plat
Date
Book
Page
Recorder’s #
2.
APPROVED SANITARY FACILITIES:
Approved Water MCESD number (s)
PWS Number
04-07
,
(Public Water System Number)
Water Supply Provider
Approved Sewer MCESD number (s)
Public Sewer System
If there are any grinder pumps, provide lot numbers
On-lot sewage disposal system/septic (See on-site sewage disposal/septic subdivision requirements on ATC application)
Approved Geological Report For Subdivisions MCESD number.
Refuse Collection Agency
Approved Refuse Disposal Site
3.
PROJECT OWNER / RESPONSIBLE PARTY: This information will be used on the certificate
Name
Job Title
(Please print clearly) (Must be a person with fiduciary responsibilities associated with the Project Company)
E-mail address of person working on project
Project Company Name
Mailing Address
City
State
Zip Code
Phone number
Fax
Engineer Working on Project
Engineer Name
Registration Number
Engineer Firm
Engineer E-mail Address
I verify that all information given in this application is accurate. I am informed that no construction of sanitary facilities shall commence unless and until a
"Certificate of Approval to Construct" is issued by MCESD. I am informed that no operation of sanitary facilities shall commence unless and until a "Certificate
of Approval of Construction" is issued by MCESD.
Project Owner’s / Responsible Party Signature:
Date:
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:
(Permit Owner/Holder initials)
It is the responsibility of the permit holder to update the Department if there is a change in contact information.
Revised June 2012 - Fillable
ENVIRONMENTAL SERVICES DEPARTMENT
501 N. 44
th
St., Suite 200
Phoenix, AZ 85008
Division of Water and Waste Management
Subdivision Infrastructure & Planning Program
P
hone (602) 506-1058
Application for Approval of Sanitary Facilities for Subdivision
Page 2 of 3
This agreement MUST be signed by the Providers NOT the Engineer or Project owner.
WATER SERVICE AGREEMENT - An unconditional agreement which is effective this date has been made
between the owners of:
Subdivision Name
and the
(name of the water system or municipality)
to provide water service to each and every lot in accordance with the design shown on the attached plans of
the subdivision.
The undersigned hereby agrees to inspect this project during construction to assure compliance with plans and
specifications approved by the Maricopa County Environmental Services Department (MCESD) and upon
completion and acceptance by MCESD shall be responsible for maintenance and operation of the system
.
Date
Print Name clearly
Job Title
Address
City
Signature
This agreement MUST be signed by the Providers NOT the Engineer or Project owner.
SEWER SERVICE AGREEMENT - An unconditional agreement has been made between the owner/s of:
Subdivision Name
and the
(name of the sewer system or municipality)
to provide sewer service to each and every lot in accordance with the design shown on the attached plans of
the subdivision.
The undersigned hereby agrees to inspect this project during construction to assure compliance with plans and
specifications approved by the Maricopa County Environmental Services Department (MCESD) and upon
completion and acceptance by MCESD shall be responsible for maintenance and operation of the system
.
Date
Print Name clearly
Job Title
Address
City
Signature
Revised June 2012 - Fillable
ENVIRONMENTAL SERVICES DEPARTMENT
501 N. 44
th
St., Suite 200
Phoenix, AZ 85008
Division of Water and Waste Management
Subdivision Infrastructure & Planning Program
Phone (602) 506-1058
Application for Approval of Sanitary Facilities for Subdivision
Page 3 of 3
This agreement MUST be signed by the Providers NOT the Engineer or Project owner.
REFUSE SERVICE AGREEMENT - Agreements must be completed and signed by a representative of the
collection service and the operational authority of the disposal site
:
Collection Agency
Refuse collection service to
(name of the subdivision)
in accordance with applicable rules and regulations governing refuse collection.
Date
Print Name clearly
Job Title
Address
City
Signature
** IN ORDER TO APPROVE THE ABOVE COLLECTION SERVICE,
WE MUST ALSO HAVE THE INFORMATION IN THE AGREEMENT BELOW.
**
This agreement MUST be signed by the Providers NOT the Engineer or Project owner.
REFUSE DISPOSAL AGREEMENT - As required by the Arizona Department of Environmental Quality Rules and
Regulations, and specifically regulation A.A.C. R18-5-409:
The Disposal Site
is operated by
(name of operational authority)
in accordance with applicable rules and regulations governing refuse and will accept refuse from persons living in:
Name of Subdivision:
Date
Print Name clearly
Job Title
Address
City
Signature
The signatures can not be more then 1 (one) year old (page 2 and page 3).
IF YOUR PROJECT IS IN THE CITY OF PHOENIX - Subdivision/Condominium Refuse
must be signed by the City of Phoenix. No Exceptions.
Revised June 2012 - 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.
Date:
I hereby authorize
, of
firm to file this
(engineering firm / organization)
application and act on my behalf for project(s) name(s) listed:
Project Owner/Responsible
Party Name / Title:
/
(Please print clearly) 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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Completed 6 August 2020

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