(A) Residential application.
RESIDENTIAL BUILDING SEWER APPLICATION
To the Village of Washburn, Illinois
A. THE UNDERSIGNED, being the ___________________________________ property located
(Owner, Owner’s Agent)
(Owner, Owner’s Agent)
at ___________________________________ DOES HEREBY REQUEST a permit to install and
Number Street
Number Street
connect a building to serve the Residence at said location.
1. The following indicated fixtures will be connected to the proposed building sewer.
Number Fixtures Number Fixtures
_________ Kitchen Sinks _________ Water Closets
_________ Lavatories _________ Bath Tubs
_________ Laundry Tubs _________ Showers
_________ Urinals _________ Garbage Grinders
Specify other fixtures _________________________________ .
2. The maximum number of persons who will use the above fixtures is _________________.
3. The name and address of the person or firm who will perform the proposed work is ____________________________________________ .
4. Plans and specifications for the proposed building sewer are attached hereunto as Exhibit “A”.
B. In consideration of the granting of this permit, THE UNDERSIGNED AGREES:
1. To accept and abide by all provisions of the Village Code of the Village of Washburn and of all other pertinent ordinances or regulations that may be adopted in the future;
2. To maintain the building sewer at no expense to the Village of Washburn; and
3. To notify the Village Department of Water and Sewer when the building sewer is ready for inspection and connection to the public sewer, but before any portion of the work is covered.
DATE:______________________________ SIGNED: ___________________________
(Applicant)
(Applicant)
____________________________
(Address of Applicant)
(Address of Applicant)
__________________________________
Village Treasurer
Village Treasurer
$___________________ connection fee paid.
$___________________ inspection fee paid. Department of Water and Sewer for the Village of Washburn, Illinois
Application approved and permit issued:
DATE: _________________________ By: _____________________________
Its: _____________________________
(B) Private application.
PRIVATE SEWAGE DISPOSAL APPLICATION
To the Village of Washburn, Illinois
A. THE UNDERSIGNED, being the __________________________________________
(Owner, Owner’s Agent)
(Owner, Owner’s Agent)
of the property located at ____________________________________________________
Number Street
Number Street
DOES HEREBY REQUEST a permit to install sanitary sewage disposal facilities to serve the ___________________________________ at said location.
(Residence, Commercial Building, etc.)
(Residence, Commercial Building, etc.)
1. The proposed facilities include:
_________________________________________________________________________________
to be constructed in complete accordance with the plans and specifications attached hereunto as Exhibit “A”.
2. The area of the property is _______________ square feet (or ____________ square meters).
3. The name and address of the person to be served by the proposed facilities is:___________ .
4. The maximum number of persons to be served by the proposed facilities is:_____________ .
5. The locations and nature of all sources of private or public water supply within the 100 feet (30.5 meters) of any boundary of said property are shown on the plat attached hereunto as Exhibit “B”.
B. In consideration of the granting of this permit, THE UNDERSIGNED AGREES:
1. To furnish any additional information relating to the proposed work that shall be requested by the Department of Water and Sewer;
2. To accept and abide by all provisions of the Village Code, of the Village of Washburn, and of all other pertinent ordinances or regulations that may be adopted in the future;
3. To operate and maintain the wastewater disposal facilities covered by this application in a sanitary manner at all times, in compliance with all requirements of the Village and at no expense to the Village of Washburn; and
4. To notify the Department of Water and Sewer at least 24 hours prior to commencement of the work proposed, and again at least twenty-four (24) hours prior to the covering of any underground portions of the installation.
DATE: __________________________ SIGNED:______________________________
(Applicant)
(Applicant)
______________________________
(Address of Applicant)
(Address of Applicant)
$ ___________ inspection fee paid.
_____________________________
Application approved and permit issued: Department of Water and Sewer for the Village of Washburn, Illinois
DATE: ___________________________ By: ________________________________________
Its: ________________________________________
(C) Institutional application.
COMMERCIAL, INSTITUTIONAL/GOVERNMENTAL, AND INDUSTRIAL SEWER CONNECTION APPLICATION
To the Village of Washburn, Illinois
A. THE UNDERSIGNED being the ____________________________ of the property located at
(Owner, Lessee, Tenant, etc.)
(Owner, Lessee, Tenant, etc.)
_________________________________________________________________ DOES HEREBY REQUEST a permit to
_______________________ an industrial sewer connection serving the
(Install, Use)
(Install, Use)
______________________________________________, which company is engaged in
(Name of Company)
(Name of Company)
___________________________________ at said location.
1. A plat of the property showing accurately all sewers and drains now existing is attached hereunto as Exhibit “A”.
2. Plans and specifications covering any work proposed to be performed under this permit is attached hereunto as Exhibit “B”.
3. A complete schedule of all process waters and industrial wastes produced or expected to be produced at said property, including a description of the character of each waste, the daily volume and maximum rates of discharge, and representative analyses, is attached hereunto as Exhibit “C”.
4. The name and address of the person or firm who will perform the work covered by this permit is ____________________________________________
_______________________________________________________________________________________
B. In consideration of the granting of this permit THE UNDERSIGNED AGREES:
1. To furnish any additional information relating to the installation or use of the industrial sewer for which this permit is sought as may be adopted in the future;
2. To operate and maintain a control manhole and any waste pretreatment facilities, as may be required as a condition of the acceptance into the public sewer of the industrial wastes involved in an efficient manner at all times, and at no expense to the Village of Washburn;
3. To cooperate at all times with the Department of Water and Sewer and his representative in their inspecting, sampling, and study of the industrial wastes, and any facilities provided for pretreatment; and
4. To notify the Department of Water and Sewer immediately in event of any accident, negligence, or other occurrence that occasions discharge to the public sewers of any wastes or process waters not covered by this permit.
DATE:__________________________________ SIGNED:__________________________________
(Applicant)
(Applicant)
____________________________________
(Address of Applicant)
(Address of Applicant)
______________________________
Village Treasurer
Village Treasurer
$ _____________ connection fee paid.
$ _____________ inspection fee paid.
Application approved and permit granted: Department of Water and Sewer for the Village of Washburn, Illinois
DATE:________________________ By: ___________________________
Its: ___________________________
(D) Attachment. The purpose of a user charge system is to generate revenues from each user class commensurate with the operation, maintenance, and replacement (OM&R) cost incurred by the village to provide such users with wastewater treatment services. A user charge system is comprised of two elements: the legislative enactments (ordinances) and the engineering/accounting data necessary to demonstrate the proportionality of the user charge system using a cost-rate-revenue relationship. Information pertaining to the UCS should, as a minimum, include the following:
ENGINEERING/ACCOUNTING DATA
1. Number of users by class:
Residential ____________________
C Commercial ____________________
Industrial ____________________
Institutional/Governmental ____________________
2. Billable flow and loading by user class:
Annual Billable Flow BOD (lbs/day) SS Flow (lbs/day)
Residential ___________ ___________ ___________
Commercial ___________ ___________ ___________
Industrial ___________ ___________ ___________
Institutional/Governmental ___________ ___________ ___________
Total ___________ ___________ ___________
3. Total annual flow (including I&I): ______________________________________________ .
4. Loading concentrations by user class:
BOD (mg/l) SS (mg/l) Other (mg/l)
Residential ___________ ___________ ___________
Commercial ___________ ___________ ___________
Industrial ___________ ___________ ___________
Institutional/Governmental ___________ ___________ ___________
5. Itemized operation, maintenance, and replacement budget for the grantee’s treatment works, or estimates for the first year OM&R budget. This budget should include costs for treatment, conveyance, collection, and billing, but should not include local capital costs. Capital costs should be shown separately. (See Attachment.)
6. OM&R costs (exclusive of costs for debt service) should be proportioned by volume and strength. Specifically, show unit costs per unit of volume and strength (i.e. cost per 1,000 gallons, cost per lb. of BOD, cost per lb. of suspended solids).
7. OM&R costs by class (exclusive of costs for debt service):
Residential ___________________________
Commercial ___________________________
Industrial ___________________________
Institutional/Governmental ___________________________
Total OM&R Costs ___________________________
8. Please show the following rates and exhibit the calculations used in their formulation:
Basic User Charge (per unit volume) ___________________________
Minimum User Charge (if applicable) ___________________________
Debt Service Charge ___________________________
Surcharge Rates for BOD (per lb) ___________________________
Surcharge Rates for SS (per lb) ___________________________
9. Based on the proposed rates, estimate the revenues to be generated annually from each user class. This should be exclusive of revenue generated for debt service.
Residential ___________________________
Commercial ___________________________
Industrial ___________________________
Institutional/Governmental ___________________________
Total Revenue ___________________________
SUGGESTED BUDGET LINE ITEMS
A. Operation, maintenance, and replacement costs including:
1. Salaries for treatment, sewers, and billing operations: (include indirect salary costs - retirement, health insurance, FICA, and other fringe benefits);
2. Power costs;
3. Treatment plant supplies: (tools, lab equipment, samplers, meters, etc.);
4. Chemicals;
5. Sewer maintenance;
6. Transportation equipment and maintenance: (vehicles, etc.);
7. Office supplies and equipment;
8. Insurance;
9. Contractual professional services: (legal, audit, engineering); and
10. Replacement: (plant, pumping stations). Please provide a replacement schedule detailing the items to be replaced. This schedule must include, as a minimum, all items with a useful life less than that of the treatment works, but may include replacement costs for any sewage works facilities.
B. Debt service and capital improvements including:
1. Debt service; and
2. Capital improvements: (costs for future expansion).
(Ord. 96-3, passed 6-17-1996)