Looking for a Njdep Forms And Templates? Download it for free!

RAHWAY VALLEY SEWERAGE AUTHORITY

TREATMENT WORKS SEWER CONNECTION

CONSTRUCTION AND DISCHARGE PERMIT (CONT’D.)

(2001 – 7999 GPD)

Population to be served:______________________ Patrons served:___________________

Anticipated Design Flow:_________________________________________ gpd

Infiltration: (none allowed) 0 = 0 gpd

(2001 – 7999)

Provide explanation of how “Anticipated Design Flow” was calculated:________________________________________

________________________________________________________________________________________________________

Application Fee of $125.00, payable to RVSA, must be submitted with your application.

Circle one: Cash / Check

Name on Check:__________________________________

Check #__________________

RVSA Receipt #__________________

One (1) set of plans (utilities only) must be submitted with your application. Attached: Yes________ No__________

I have included Certification of any Public Notifications: Yes______________ No______________

Endorsement by Municipal Official obtained: Yes______________ No______________

Name:_______________________________________ Title:________________________________________________

Authorization to Sign Application Resolution dated:_________________________________

Copy of Resolution attached: Yes______________ No______________

Source of Water Supply:__________________________________________________________________________________

Rahway Valley Sewerage Authority Resolution #__________________ Date:____________________________________

Note: Your original signed application along with the plans and application fee must be submitted to the RVSA by

the first Thursday of the month in order to be considered by the Board of Commissioners during that month. Please

include any other documents that you think are pertinent to your application.

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

2 of 2

Treatment Works Sewer Connection Construction And Discharge Permit Form - Rahway Valley Sewerage Authority Page 2