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1/31/2008

11:06 AM

Page 1

RHODE ISLAND DEPARTMENT OF ENVIRONMENTAL MANAGEMENT

ONSITE WASTEWATER TREATMENT SYSTEM CONSTRUCTION PERMIT

FOR RIDEM USE ONLY

APPLICATION No.

___________________________ DATE RECEIVED ____/____/____ AMOUNT RECEIVED $_________ CHECK #________ NOTE__________

TYPE OF APPLICATION (CHECK ALL THAT APPLY)

CERTIFICATION

❑ ❑

NEW BUILDING CONSTRUCTION

A/E TECHNOLOGY

I, _________________________________________________________ (print), the undersigned licensed OWTS designer, certify that

❑ ❑

I prepared this application and accompanying forms, submittals, plans and sketches in accordance with the RULES of the RIDEM

ALTERATION

TYPE OF SYSTEM _______________________________

pertaining to OWTS and that all the information provided on this application and accompanying forms, submittals, plans and

❑ ❑

REPAIR

VARIANCE

sketches is true and accurate.

❑ ❑

TRANSFER

REDESIGN

Signature of Designer __________________________________________________________

SITE INFORMATION

Designer License Number _____________________ Phone # __________________________

Business/Company Name _______________________________________________________

NO. STREET

CITY/TOWN

POLE #

I certify that a) I am the owner of the property indicated under the site information on this application, b) I will hire a licensed

OWTS installer to install the system proposed herein, c) the system will be installed in strict accordance with this application,

PLAT NUMBER _____________ LOT NUMBER___________ SUBDIVISION LOT NUMBER________

d) I will hire and retain the licensed OWTS designer of record to witness and inspect the installation of the system, e) I assume

LOT SIZE ______________SQUARE FEET

all responsibility for the truth and accuracy of this application and all liability and responsibility for any improper installations of

the system on this site and agree to hold the RIDEM harmless from any and all claims relating whatsoever to the system. In

SUBDIVISION NAME _________________________________________________________________

the case of a transfer application, I acknowledge that the permit application and plans previously approved and accompanying

this application are the operative documents subject to certification.

SUBDIVISION SITE SUITABILITY CERTIFICATION # ______________

Owner(s) Signature _________________________________ Phone Number ___________________

OWNER INFORMATION

PERMIT APPROVAL SECTION: DO NOT WRITE BELOW THIS LINE

Based upon the representations of the owner and the owner's agents, including the representations of the owner's OWTS designer,

and the truth and accuracy of all information submitted, this application for an OWTS is hereby approved. The RIDEM assumes no

LAST NAME

FIRST NAME

M.I.

responsibility or liability for the future safe operation or maintenance of the aforesaid system, of the fitness or suitability of this system

to this site, nor does it assume any responsibility for the accuracy and truth of the owner's, or the owner's agent's representations. This

approval is subject to future suspension or revocation in the event that subsequent examination reveals any data indicated on any

NO. STREET

CITY/TOWN

ZIP CODE

application, form, submittal, plan or sketch to be incorrect, or not in compliance with the RULES or any conditions at the site are such

that the approved design is not in accordance with the RULES, or in the event that the system discharges inadequately treated

RIDEM APPLICATION HISTORY

wastewater to waters of the State or fails to operate satisfactorily in any other manner.

❑ ❑

PREVIOUS SITE TESTING

IMPORTANT: Additional terms of approval as circled.

YES

NO APPLICATION # _______________________________

A. Bottom of leaching area excavation must be inspected by the RIDEM prior to placement of any gravel or stone.

DEPTH TO APPROVED WATER TABLE ________ HOW DETERMINED ________________________

B. System installation must be inspected by RIDEM prior to covering any component of the system with backfill.

❑ ❑

C. Applicant shall comply with all requirements, conditions and stipulations of variance(s) approved on _____________________ .

TEST HOLE # ______ DATE EXCAVATED ____/____/____ WETLANDS within 200’ OF OWTS

YES

D. A/E Technology: additional specific installation, operation, or maintenance requirements may apply (see RIDEM A/E Technology

certification for this system type.)

❑ ❑

WETLAND DETERMINATION

YES

RIDEM FILE # ___________

DATE ____/____/____

E. Copy of this form and Operation/Maintenance contract must be filed in land evidence records prior to conformance.

❑ ❑

F. Proposed construction falls within “Coastal Zone”. Contact Rhode Island Coastal Resources Management Council.

LARGE SYSTEM

YES

G. Proper erosion and sedimentation controls must be installed prior to start of construction.

H. Transfer: See original permit for all applicable conditions.

DESIGN INFORMATION

I. Other

❑ ❑

BUILDING USE:

Residential

Commercial ____________________________________

❑ ❑

Other ____________________________________________

❑ ❑

WATER SUPPLY:

public water

public well

private well

# OF DESIGN UNITS ____________

UNIT DESIGN FLOW _______ gallons per ______ (unit) TOTAL DAILY FLOW ____________ gallons

TANK SIZE ____________ gallons DESIGN LOADING RATE __________________________ gpd/sf

MINIMUM REQUIRED LEACHFIELD AREA ______________ square feet

Signature of RIDEM Official

Date of Approval

Date of Expiration

LEACHFIELD TYPE __________________________________________________________________

TOTAL AREA OF LEACHFIELD PROVIDED ___________ square feet

Onsite Wastewater Treatment System Construction Permit Form - Rhode Island Department Of Environmental Management

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