[   ]  Existing facility presently discharging to system.  Attach copy of connection permit.
  [   ]  Existing facility not presently discharging to system.   Attach narrative of waste water disposal method.
  [   ]  Proposed or new construction.

  b)  Type of facility

[   ]  RESIDENTIAL                          [   ]  SINGLE FAMILY
                                                            [   ]  MULTIPLE FAMILY, _____ UNITS, _____ BUILDING(S)

[   ]  COMMERCIAL                         SIC CODE ____________

Description of commercial activity: ____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

[   ]  INDUSTRIAL                             SIC CODE ____________

Description of industrial activity:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
.

[    ]  Private well or river source     Is water use metered?  [   ] Yes  [   ] No  Estimate of flow ________ gallons per day.

[   ]  Residential multiple family, commercial or industrial, attach sketch on 8½ × 11 sheet or provide a site plan
        completed, signed and sealed by a registered professional engineer, licensed to practice in Michigan.

  a)  Diameter of building sewer pipe: ___________________   b)  Material Building sewer pipe: ____________________

  c)  Slope (grade) of building sewer pipe: ________________  d)   Is building sewer:  [   ]  Existing, age:_______________
       Contractor:____________________________________                                          [    ]  Proposed construction
       Public sewer: __________________________________    Bond Status:___________________________________

  d)  Diameter of public sewer pipe: _____________________    f)  Material Public sewer pipe: ______________________

   a)  Type of discharge:  [    ]  Process Wastewater  [   ]  Uncontaminated Industrial Waste  [   ]  Sanitary Wastewater

   b)  For process waste water:

Indicate discharge levels, in parts per million, of the following substances:

BOD:________________  Phosphorous:________________  Total Kjeldahl Nitrogen:________________

TSS:_________________ Oils & grease:_______________________

   c)  For all chemicals used or stored on this site, provide a description of their use(s) and methods(s) of disposal.
        Include a copy of the Material Safety Data Sheet for each.

.

One person from non-residential applicant shall be delegated by the applicant the authority to be responsible for wastes admitted to the municipal sewers.  Such persons would be charged with maintaining the wastewater discharge operation and assuring a continual high level of performance.

Such person would be involved with the prevention of accidental discharges of process wastes admitted to the sanitary sewer system.  Such person must become aware of all potential and routine toxic wastes generated by their industry.  Such person must also be informed of all process alterations which could, in any manner, increase or decrease normal daily flow or waste strength discharged to the sanitary sewers.

This industrial representative must catalog all chemicals stored, used or manufactured by their industry.  Such a listing should include specific chemical names, not manufacturer's codes.  Those wastes admitted to the sanitary sewer are a prime concern;  however, all discharges should be cataloged.  An estimate of daily average flows and strength must be made including process, cooling, sanitary, etc.   Such a determination should separate the flows according to appropriate categories.   The aforementioned flow and chemical listing is to be sent to the City.

The industrial representative shall determine whether or not large process alterations will occur during the next few years;  one year, two years, five years.   Management should be consulted to determine if such alterations are scheduled and forthcoming.

I certify that I am familiar with the waste water process at the location specified in Section 2.  By signing this section I agree to the conditions specified above.

__________________________________________________
Name of representative

__________________________________________________   _______ /_______ /________
Signature of representative                                                                               Date
.

Application is hereby made for a permit or permits to authorize the activities described herein.  I certify that I am familiar with the information contained in this application, and that to the best of my knowledge and belief such information is true and accurate.  By signing this application, I understand to allow representatives of the Ogemaw County Board of Public Works to enter upon said property in order to inspect the proposed project.  I understand that the granting of other permits by local, county, state or federal agencies does not release me from the requirement of obtaining the permit requested hereon before commencing the project.  I understand that the payment of fee does not guarantee permit.  I hereby authorize and endorse the representative named in Section 8 above. I also understand that if granted a permit, I will incur additional fees to connect to, and discharge waste water into, the West Branch Area Waste Water Treatment Plant System.

____________________________________________________
Name of applicant

____________________________________________________      _______ /_______ /________
Signature of applicant                                                                                               Date
.

Make checks payable to the City of West Branch.
In the amount of:  [   ]  $125.00 FOR A RESIDENTIAL  [    ]  $175.00 FOR A NON-RESIDENTIAL
.

  RETURN OR MAIL THIS APPLICATION ALONG WITH THE INSTRUCTION BOOKLET TO:

City of West Branch
121 North 4th Street West Branch, MI  48661

  *  A $10.00 fee will be assessed for failure to return instruction booklet