Special Or Experimental Lawn Care Containment Permit Page 2
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1
2SPECIAL OR EXPERIMENTAL LAWN CARE CONTAINMENT PERMIT
Special Lawn Care Permit
Experimental Lawn Care Permit
1. LOCATION AREA MAP .............................................................................. Is a Location Area Map attached? ( ) Yes ( ) No
Please submit the distance from facility structure to all of the following:
Community wells (if none, so indicate):
feet;
Residence:
feet
Off-site water supply wells (if none, so indicate):
feet;
Municipality:
feet
On-site wells (if none, so indicate):
feet;
Hospital:
feet
Approximate groundwater depth:
feet;
*Institution:
feet
Soil type:
Commercial Business:
feet
* - i.e. nearest school, church, etc.
Name of lake or stream and approximate distance of nearest down gradient surface water:
2. PLOT PLAN ......................................................................................................................Is a Plot Plan attached? ( ) Yes ( ) No
Please provide the approximate size of the facility:
x
feet
Drainage tile or storm sewers present?
yes;
no
Please indicate the uses of the surrounding property (check all that apply):
residential;
industrial;
agricultural;
commercial;
other (list):________________________________________________________________
3. WATER SYSTEM PROTECTION (check all that apply) ............... Is a Schematic Flow Diagram attached? ( ) Yes ( ) No
Surface water supply
Connection to public water supply
Facility well - If a facility well is used, please indicate the following:
approximate depth _______(feet); potable _______;
non-potable _______
Connections to the Water Supply (check all that apply):
Back-Flow Protection Provided:
Product pipe or manifold .........................................................................
fixed air gap (required)
Any tank filling use points .......................................................................
fixed air gap (required)
fixed air gap
OR
Wash water use points …………………………………………………...
Reduced pressure zone valve (RPZ)
Manufacturer _________________
Model # _____________________
ASSE # _____________________
4. OPERATIONS & MANAGEMENT PRACTICES PLAN
Estimate of recovered rinsates is ____________ gallons per week. Estimate of recovered solids is __________ pounds per week.
Number of recovery tanks: ____________
Capacity of each tank is __________ gallons.
Is an automatic transfer system proposed to meet the volume requirements for this structure?
yes
no
Volume of proposed recovery tank: __________ (Recovery tank must be located within
the containment structure)
Is the containment structure exposed to precipitation?
yes
no
Volume generated by a 6" rain is __________ gallons
If exposed to precipitation, is discharge of storm water proposed?
yes
no
Is discharge by: pump transfer:
yes
no
gravity drain:
yes
no other (describe): ______________
Is an underground storage or transfer structure (i.e. pits, piping, or tanks) proposed as part of the containment system?
yes __no (describe): _________________________________________________________________________________
5. PLANS AND SPECIFICATIONS
Capacity of largest application device is ____________ gallons.
Capacity of structure is __________ gallons
*Greatest dimensions of application device:
x
Inside dimensions of structure: _______ x _______ x _______
Dimensions of sump well: _______ x _______ x _______
Width of curb: __________________________________
Material of construction of the containment structure: ________________________________________________________
Is the manufacturer's statement of compatibility and life expectancy attached?
yes
no
not applicable
Please indicate which operations are to be performed upon the proposed structure (check all that apply):
mixing
washing
filling application devices;
rinsate storage;
other:____________________
6. EXPERIMENTAL PERMIT ONLY
Is a description of the quality control and quality assurance methods and supportive analytical data for the proposed system
included in the application?
yes
no
not applicable
*If a truck mounted sprayer is used, then the truck represents the greatest dimensions.
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