Treatment Works Sewer Connection Form - Rahway Valley Sewerage Authority
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3RAHWAY VALLEY SEWERAGE AUTHORITY
1050 EAST HAZELWOOD AVENUE
RAHWAY, NJ 07065
Phone (732) 388-0868 / Fax (732) 382-0774
NJPDES Permit #0024643
TREATMENT WORKS SEWER CONNECTION
(0 – 2000 GPD)
RVSA #_____________________
The following sewer connection form must be completed in lieu of a NJDEP Treatment Works Approval, pursuant to
N.J.A.C. 7:14A–22.4.
Owner/Applicant:______________________________________________ Telephone:______________________________
Email Address:_________________________________________________ Fax:____________________________________
Legal Address:____________________________________________________ Town:________________________________
State:____________________ Zip Code:____________________ County:________________________________________
Project Engineer:________________________________________________ Telephone:______________________________
Email Address:_________________________________________________ Fax:____________________________________
Legal Address:___________________________________________________ Town:________________________________
State:____________________ Zip Code:____________________ County:________________________________________
Builder:________________________________________________________ Telephone:______________________________
Email Address:__________________________________________________ Fax:___________________________________
Legal Address:____________________________________________________ Town:_______________________________
State:____________________ Zip Code:____________________ County:________________________________________
Description of Work: (For residential modification, provide existing and proposed number of bedrooms)___________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Location of Worksite:______________________________________________ Town:________________________________
State:____________________ Zip Code:____________________ County:________________________________________
Tax Map Lot Number:_________________________________ Block Number:____________________________________
Number and Type of Units (see attached page):_____________________________________________________________
Nature of Proposed Discharge: Domestic_____________ Commercial_______________ Industrial_________________
Number of Employees if Commercial or Industrial:__________________________________________________________
Anticipated Design Flow:__________________________________________gpd
Infiltration: (none allowed) 0 = 0 gpd
(0 – 2000)
Application Fee of $50.00, payable to RVSA, must be submitted with your application.
Circle one: Cash / Check
Name on Check:__________________________________
Check #__________________
RVSA Receipt #__________________
I certify that no downspouts, sump pumps or other non-contaminated water will be discharged into this connection.
I further certify that the forgoing statements made by me are true. I am aware that if any statements made herein are
false, I am subject to criminal penalties, which include incarceration.
________________________________________________
__________________________________________________
Signature of Applicant/Owner
Date
Signature of Municipality
Date
__________________________________________________
Signature of RVSA Representative
Date
Updated & Effective 7/30/13
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