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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