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16-05 Oppidan METROPOLITAN C O U N C I L Environmental Services Direct Connection Application Form Applicant Information Contact Person: Bill Sharbono or Vicki Van Dell P.E. Organization Name: Loucks Inc. Address: 55 East 5th Street Suite 910 St. Paul MN 55101 Phone Number: 763-496-6760 Fax Number: NA E-mail Address: bsharbono(cDloucksinc.com or vvandellna.loucksinc.com Description of Project Three story Senior Living building with under rg ound parking and associated surface parking and other site amenities. Location The project is located in the southwest quadrant of Highway 7&Chaska Rd, Shorewood, MN, MCES MH 15 1 Requested Date of Connection: September 1, 2016 Permit to connect expires 60 days from requested date of connection.Contact Dan Chouinard for extension. Briefly Describe any Unusual Circumstances Please Include: • Direct Connection Application Form with original signature from City Representative(P.W. Dir., Eng., Manager/Clerk). • Copy of plan sheets depicting connection location and associated details. • Application fee of$1,000, of which$450 is non-refundable. Signature: L/••c sa u Date: left Printed Flame: W/LL..R714 C3. �iF-/�iw6u C7 Rev.July 2016 Page 1 of 6 MET ROPOLITAN J N c, L . L Environmental Services Basis for Fee The connection permit application fee recovers administrative costs for time spent by MCES staff on a connection permit request(reviewing, modifying, permitting, drawing, and inspecting). Since about half of MCES staff time is spent administering a connection request before the actual connection is made, half of the fee is not refundable regardless of whether or not the connection request is approved. Please refer to MCES Waste Discharge Rules 301.1 A-F, pages 21 and 22: http://www.metrocouncil.ora/environm ent/IndustrialW aste/W asteDischargeRules.pdf. Important MCES Direct Connection Permit Process Information: 1. No connection work shall occur until a permit has been issued by MCES. Before completing any forms and paying the fee, communicate with Dan Chouinard to obtain additional interceptor information, instructions and MCES standard connection details. Phone:651-602-4564 Email:daniel.chouinardametc.state.mn.us 2. Mail the completed Connection Permit Application Form (pages 1-6)to: Dan Chouinard Metropolitan Council 3565 Kennebec Dr. Eagan, MN 55122 A copy of the Direct Connection Application Form should be accompanied by engineering plans/drawings and a$1,000 check made out to Metropolitan Council. Completion of the application form and payment of the fee does not guarantee approval for connection. 3. MCES normally requires approximately 15 days of processing for a connection application. If approved,a fully executed Connection Agreement must be in place prior to any excavation.Additional cost recovery fees may be added if any unauthorized connection is made that requires additional staff time. 4. It required that the contractor contacts Jennifer Adams at 651-602-8327, cell 651-755-3479, between 7:30 am and 3:30 pm at least 48 hours in advance to make arrangements to have an inspector on site at the time the connection is being made. Backup contacts are as follows:Adam Winiarczyk at 651-602-8930, cell 651-325- 6381 and Jim Sailer 651-602-8914,cell 651-325-6377. If the MCES inspector is not notified prior to installation of the connection, the applicant will be required to pay all costs associated with re-excavation, inspection, and restorative work. Please make reference to the assigned connection permit number when requesting an inspection. For Internal Use Only: Amount Received: Date Application Received: Date Payment Received: Rev.July 2016 Page 2 of 6 METROPOLITAN C O U N C I L Environmental Services PERMIT NO.: 1856 INTERCEPTOR: 7017-2 APPLICATION FOR CONNECTION TO OR USE OF METROPOLITAN COUNCIL ENVIRONMENTAL SERVICES FACILITIES This form and plans/drawings must be submitted to: Dan Chouinard Metropolitan Council 3565 Kennebec Drive Eagan, MN 55122 The City of Shorewood hereby applies for a permit for connection to, or use of, Metropolitan Council Environmental Services (MCES)facilities. By execution of this Application, the Applicant agrees to: 1. Provide such additional information as is requested by MCES in order to make a determination on permit issuance. 2. Abide by the permit terms and conditions set forth below and all applicable federal,OSHA, state and local laws, ordinances, rules and regulations. 3. Pay all applicable permit fees(i.e., Service Availability Charge and Industrial Strength Charge) in accordance with MCES rules and regulations. 4. Reimburse MCES for any damages resulting to MCES facilities as a result of the connection to or use of its facilities. 5. Indemnify and hold harmless MCES, its employees, agents, and contractors from and against all claims, damages, losses and expenses, including but not limited to attorney's fees, arising out of or resulting from the connection to, or use of, MCES facilities, provided that any such claim, damage, loss or expense (1)is attributable to bodily injury, sickness, disease, or death or to injury to or destruction of tangible property, including the loss of use resulting therefrom,and(2)is caused in whole or in part by any negligent act or omission of the Applicant, its contractors, subcontractors, or anyone directly or indirectly employed by any of them, regardless of whether or not it is caused in part by MCES. 6. Construct the connection in accordance with applicable MCES standards. 7. At Applicant's own expense,Applicant will promptly make any repairs necessitated by the failure or malfunction of the connection. MCES will inform Applicant of the necessity of such repair in writing.Applicant will notify MCES at least 48 hours prior to making said repairs. Applicant further agrees that if Applicant fails to make such repair within sixty(60)days of date of written notice by MCES to Applicant of the necessity of such repair, MCES shall make such repair and bill Applicant for the full cost of such repair.Applicant hereby agrees to promptly reimburse MCES for the full cost of any repair made by MCES to remedy a failed or malfunctioning connection. 8. Applicant operates and maintains the connection. 9. Pertinent details of the connection are as follows(see next page): Rev.July 2016 Page 3 of 6 Connection Details: Please attach map showing location(s). Exact Location of Connection(i.e.,with reference to street intersections, nearest maintenance access structures, etc.): Direct connection to manhole in Chaska Rd. 352.55 feet south of manhole lust off the Highway 7& Chaska Road intersection. MCES MH 151. Work to be done by: General Contractor is Anderson Companies—utility contractor TBD Phone No.: Shane Walgamuth(952-746-1466) Type of Connection: Core-Drill into existing MH Depth: 9.4 ft If connection includes installation of a new on-line M.H.,or adjustment to existing M.H.elevation, please complete page 5. Approx. Date of Connection: September 1, 2016 Size of Connection Sewer: 8" Pipe Material: PVC, SDR 26 (i.e., PVC, DIP, etc.) Invert Elevation of Connection: 947.0 Invert Elevation of Existing Sewer: 946.90 Area Served in Acres: Residential 3.7 Commercial Industrial Predicted Flow in Gallons Per Day: Initial 28,770 Design 28,770 105 units*274 gallons per day=28,770 GPD Characteristics of Discharge: Residential Typical Commercial Industrial Unusual Characteristics of Above(Strength, Oils, Chemicals, Temperature,etc.) This Application is hereby made this Vt day of u Cs+►1ST, 20 Ike . CITY OF Other BY (Signature of City Official) PRINT NAME ��,t_. TITLE: e_',rr--J fie-16x..3 ADDRESS: 15r— lWjb Mc4 �M ) PHONE: �l$2.— 7L0 7910 FAX: J�—_ —OIZfS Rev.July 2016 Page 4 of 6 Manhole Modification Details: Please attach map showing location(s). Interceptor: -701-7-Z Construction Year: Address of Manhole/Feature: AxaS yylw� tS-) Distance to Next Upstream Manhole/Feature: 352 Downstream: 352 Please complete applicable information. Ex.Surface El.: Pro. Surface El.: Ex. Rim El.: P-W-4 Pro. Rim El.: it�4-4 Adjustment to existing M.H.casting elevation: Raise Lower� 42�- _ Flow: Invert up: Invert down: Surface Type: BlacktoplK Concrete❑ Ground❑ Wtr/Swmp❑ Unknown❑ Cover Type: Non-ventedA Vented I Center pick❑ 2-4 Holes❑ 5 Holes ❑ 6 or More❑ Seal tight❑ Manufacturer&Model No.: Cover: Diameter Thickness MH Type: PC❑ PP❑ BB❑ PIP❑ MH Size: Adjustable Rings: 2"❑ 4"❑ 6"❑ risers Number of Rings: M.H. Steps: Poly/Steel: Aluminum: Cast Iron: NONE: Inlet Sewer n Size: Shape: Circular 171 Arch❑ Egg❑ Elliptical ❑ Rectangular❑ Horseshoe❑ Type: Asbestos❑ Brick/Block❑ Brick/Sdstone❑ Brick/Stone❑ CIP❑ CIPP❑ Conc./Unreinf. ❑ CMP❑ DIP❑ HDPE❑ HDPE/DRLP❑ HDPE/PB ❑ HDPE/SL❑ PCCP❑ PIP/Reinf. ❑ PIP/Unreinf❑ PVCAQ PVC/CP❑ PVC/CP/SL ❑ PVC/SL❑ RCP❑ RCP/Brick❑ RCP/RSJOINT❑ RPMP❑ RTRP❑ SJP❑ Steel ❑ Stone❑ Stone/Conc./Brkinv❑ VCP❑ VCT❑ Outlet Sewer Size: got Shape: Circular Arch El Egg❑ Elliptical ❑ Rectangular❑ Horseshoe❑ Type: Asbestos❑ Brick/Block❑ Brick/Sdstone ❑ Brick/Stone❑ CIP❑ CIPP❑ Conc./Unreinf. ❑ CMP❑ DIP❑ HDPE❑ HDPE/DRLP❑ HDPE/PB ❑ HDPE/SL❑ PCCP❑ PIP/Reinf. ❑ PIP/Unreinf❑ PVC K PVC/CP❑ PVC/CP/SL❑ PVC/SL❑ RCP❑ RCP/Brick❑ RCP/RSJOINT❑ RPMP❑ RTRP❑ Sip❑ Steel ❑ Stone❑ Stone/Conc./Brkinv❑ VCP❑ VCT❑ General Comments: h% U-Jrr &PUO.-- I;, �trN•-fir GThl� 73 L.XiS-rielG � G NYXS 1�J- .c��vT y►'bl~} 5��4>tc� �S B" 1�- �.+fir Z� . Service/Lateral Information Rev.July 2016 Page 5 of 6 Size: Type: _ _ Depth: Flow: Orientation to North: PERMIT NO.: 1856 PERMIT FOR CONNECTION TO OR USE OF METROPOLITAN COUNCIL ENVIRONMENTAL SERVICES FACILITIES It has been determined that Applicant has adopted a comprehensive sewer plan, has submitted it to MCES as required by law, and that the proposed connection to, or use of, MCES facilities conforms to the adopted comprehensive plan or adopted revisions thereof. Permission is hereby granted to Applicant for connection to, or use of, MCES facilities in accordance with the description provided by Applicant. This permit is issued under the following terms and conditions: 1. The provisions of the Waste Discharge Rules for the Metropolitan Disposal System, Minn. Rules, Chapter 5900, apply to activity carried out under this permit. 2. This permit does not replace permits required by the Minnesota Pollution Control Agency or the necessity of securing other permits and fulfilling requirements of other governmental units. 3. MCES issuance of this permit does not constitute a certification that the project design and construction proposed by Applicant meet engineering standards or local codes.Applicant remains responsible for design and construction, including safety,for the project. Applicant's attention is specifically directed to the confined space rules adopted by the Minnesota Department of Labor and Industry, OSHA Regulations, Parts 5202.100 through 5205.1040 and 5207.0300. 4. The connection shall be constructed in accordance with MCES standards attached hereto [PL{s) 5. This permit shall be null and void if the connection proposed by Applicant is not made within 90 days from the date of issuance, unless an extension is granted by MCES. 6. This permit is subject to modification or revocation and may be suspended at any time for failure to comply with its terms. 5. Record Drawing information provided by MCES is not guaranteed accurate but is included 5j information available to,and in use by, MCES. 8. Contractor shall take measurements before beginning construction to ensure that service connections shall not cut into maintenance access structure joints or pipe barrel joints. Cutting into joints will not be allowed. 9. Applicant is required to contact MCES 48 hours in advance of the initiation of the connection at telephone number 651-602-8930. Failure to do so will require applicant to pay for all costs associated with re-excavation, inspection, and restorative work. 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