Wyoming Water Quality Application for a Chapter 3 Permit ...

App. No. _____________

Wyoming Water Quality Application for a Chapter 3 Permit to Construct

This application is for permits to construct water or wastewater treatment facilities, water distribution or wastewater

collection facilities, subdivision reviews, or land application of wastewater. Submit 3 copies of your complete

application package (including this form and applicable investigations, design reports, plans, specifications, etc.) as

described in Water Quality Rules and Regulations, Chapter 3 to the appropriate District Office address listed below. A

District map can be viewed at:

For the Southeast District, submit completed packages to:

WQD Use Only

DEQ/ Water Quality Division 200 W 17th Street, Suite 400

Cheyenne, WY 82002

(307) 777-7781

For the Northeast District, submit completed packages to:

DEQ/Water Quality Division

152 North Durbin Street, Suite 100

Casper, WY 82601

(307) 473-3465

For the Northwest and Southwest Districts, submit completed packages to:

DEQ/Water Quality Division

510 Meadowview Drive Lander, WY 82520

(307) 332-3144

Name of Project: Project Description:

County:

Location:

? ? Section: Decimal Latitude: Subdivision Name:

Section:

Township: Decimal Longitude:

Lot and Block:

Range:

Real Estate/Land/Easement/Development Owner

Operator or Developer

Printed Name:

Printed Name:

Title:

Title:

Mailing Address:

Mailing Address:

City, State:

Zip:

City, State:

Zip:

Phone Number:

Phone Number:

Email:

Email: Consulting Engineer/Geologist

Printed Name:

Company Name:

Title:

Mailing Address:

Phone Number:

City, State:

Zip:

Email:

WY P.E.#:

WY P.G.#

May 2017

Authority: The Wyoming Environmental Quality Act, W.S. 35-11-101 and Article 3, W.S. 35-11-301 requires permits for construction or modification of public water supplies, wastewater facilities, land application systems, and confined swine feeding operations. W.S. 18-5-306 requires review of the safety and adequacy of proposed sewage systems and water systems in new subdivisions by DEQ. Please select all rules that apply to the permitting of your project from the list below. A list of all current Water Quality rules and regulations may be found at:

Check All Chapter

Description of Rule Chapters

That Apply Number

Design and construction standards for sewerage systems, treatment works, disposal systems or

other facilities capable of causing or contributing to pollution. This chapter also includes 11 mobile home park and campground sewerage, public water supply distribution systems, road

application of wastewater, and reuse of treated wastewater.

Design and construction standards for public water supplies, including subdivision water 12 supplies and water line extensions.

Permitting, design, and operation standards for confined swine feeding operations.

Applications must include the following four components:

Construction Plan as described in Section 8

20

Operation Plan as described in Section 9

Animal Waste Management Plan as described in Section 10

Financial Assurance, Closure and Corrective Action Plan as described in Section 11

23

Minimum standards for subdivision application, including water and wastewater infrastructure.

Septic tank and/or soil absorption systems and other small wastewater systems. This form is

25 required for all engineered non-conventional systems. Do not use this form if you are already

using a DEQ designed application package.

Well construction standards for commercial, municipal and industrial waste wells; special

26 process discharge wells; artificial recharge and miscellaneous discharge wells; geothermal

wells; observation and monitoring wells; and test wells.

Other Briefly describe:

Previous or Associated State Of Wyoming Permits WQD Permit to Construct (Chapter 3 Permit) WQD Subdivision Recommendation to County WQD Underground Injection Control (UIC) WQD CAFO Permit WYPDES Discharge Permit Oil and Gas Commission Solid and Hazardous Waste State Engineers Surface Water Right or Well Permit US EPA Public Water Supply (PWS) Number Other

Permit Number

May 2017

Page 2 of 3

Access Route

As part of this application, the applicant shall certify under penalty of perjury that the applicant has secured and shall maintain permission for Department of Environmental Quality personnel and their invitees to access the permitted site, including (i) permission to access the land where the site is located, (ii) permission to collect resource data as defined by Wyoming Statute ? 6-3-414, and (iii) permission to enter and cross all properties necessary to access the site if the site cannot be directly accessed from a public road. A map of the access route(s) to the site shall accompany this application.

Attach map as a separate sheet.

Signatures

All undersigned certify under penalty of perjury that the owner or applicant has secured and shall maintain permission for Department of Environmental Quality personnel and their invitees to access the permitted site, including (i) permission to access the land where the site is located, (ii) permission to collect resource data as defined by Wyoming Statute ? 6-3-414, and (iii) permission to enter and cross all properties necessary to access the site if the site cannot be directly accessed from a public road.

All undersigned agree to comply with all applicable Wyoming Statutes and Regulations and to allow the activities described in this application.

Real Estate/Land/Easement/Development Owner

(Signature Required)

Operator or Developer

A legally binding authority must sign if the owner or easement grantee is a public entity, partnership, or corporation; otherwise leave this section blank.

Signature:

Signature:

Printed Name:

Printed Name:

Title:

Title:

May 2017

Page 3 of 3

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