ࡱ> npm @ KbjbjFF T,,W4<"<"<"h"(#4M4h#8%L%%%(vz(D($3333333$95R73E+''@++3%%4y.y.y.+.8%,R%3y.+3y.y.V1@~"2%\# JkM<"+1 3|40M410w8=,w82w82(vX)Ty.)D)(((33dW." APPLICATION FOR APPROVAL OF CONTRACT DOCUMENTS SECTION I - - APPLICANT INFORMATION Property Owner:  FORMTEXT       Phone:  FORMTEXT       Street:  FORMTEXT      , City:  FORMTEXT      , State:  FORMTEXT    Zip:  FORMTEXT       E-Mail:  FORMTEXT       Developer:  FORMTEXT       Phone:  FORMTEXT       Street:  FORMTEXT      , City:  FORMTEXT      , State:  FORMTEXT    Zip:  FORMTEXT       E-Mail:  FORMTEXT       Engineer:  FORMTEXT       Phone:  FORMTEXT       Street:  FORMTEXT      , City:  FORMTEXT      , State:  FORMTEXT    Zip:  FORMTEXT       E-Mail:  FORMTEXT       SECTION II - - PROJECT INFORMATION Project Name:  FORMTEXT       Location:  FORMTEXT       Name of STP:  FORMTEXT       Capacity Approved  FORMTEXT       (GPD) Date:  FORMTEXT       (Attach previously approved Capacity Request. Application will not be accepted without approved request form) SECTION III - - DESIGN INFORMATION The following MUST accompany your application and it will not be reviewed unless the following items are attached. (Underline indicates the form is available on the MSD website.)  FORMCHECKBOX  KY Division of Water Application for Sewer Extensions, fee, USGS Quad Map  FORMCHECKBOX  Two sets of plans.  FORMCHECKBOX  Computations for Sanitary Sewer Design and Sewer Service Area Map  FORMCHECKBOX  Copy of record plat and easement plats (recorded or unrecorded).  FORMCHECKBOX  Approved Request for Sanitary Sewer Capacity form.  FORMCHECKBOX  Proposed Project Plan.  FORMCHECKBOX  Pump Station Specifications and Calculations (when applicable).  FORMCHECKBOX  Sewer Extension Special Provisions SECTION IV - - TERMS AND CONDITIONS OF APPLICATION AND APPROVAL MSD review plans, specifications and other documents needed for construction of the sanitary sewer system, treatment plant or treatment plant expansion based upon the design practice and standards of MSD. No Lateral Extension shall be approved unless they conform to MSDs comprehensive plans for sewering Jefferson County. No sanitary sewer system shall be approved unless the receiving treatment facility has a Kentucky Pollutant Discharge Elimination System (KPDES) permit or a National Pollutant Discharge Elimination System (NPDES) permit which has not expired. Application for approval of sanitary sewer design shall constitute agreement that the system/ facilities being submitted for approval will be connected to the MSD Master Plan Facilities when available. At the time of said connection, all necessary rights to the sanitary sewer collection system in public right-of-way and/or easements shall revert to MSD at no cost to the agency. Lateral Extensions shall not be approved unless the developer agrees to grant MSD all necessary sewer and drainage easements. Submittal and subsequent approval of construction or expansion of treatment plants shall constitute agreement that the plant will be eliminated by connection to an MSD Master Plan Facility when available. No construction of an approved Lateral Extension project shall begin until the developer has obtained and received all necessary permits required to be obtained by the developer and has paid all applicable fees including, but not limited to, Capacity Charges, Recapture fees, Pump Station telemetry and Connection Fees. Within sixty (60) days of the completion of this project Developers Land Surveyor shall prepare the Final Record Drawings in accordance with the Special Provisions and the PSC/LE Procedures. All changes made during the construction process shall be certified by a Professional Engineer licensed in Kentucky and submitted to MSD and to KY DOW affirming that construction has been carried out in accordance with the Contract Documents except for the changes made and identified on the record drawings and that the location of the sewer and drainage easements relating to the sanitary sewer as shown on the record or easement plat agree with their respective locations as shown on the construction plans. MSD approval of Contract Documents shall be valid for a period of one (1) year after the date of approval. I acknowledge receipt of the terms and conditions of MSDs review and approval submitted with this application. MSDs review and approval is pursuant to KRS Chapter 76. I understand that knowingly providing false information on this application may result in any action taken hereon being declared null and void, and that, pursuant to KRS 523.010 et seq., knowingly making a false statement or providing false information with the intent to mislead a public servant is punishable as a Class B misdemeanor. Applicants Signature___________________________________________________ Date ________________ (Developer) Applicant (Printed)_____________________________________________________________________ COMMONWEALTH OF KENTUCKY ^`bdftvx   ζ¢weSMCMhh/hYm5CJ hd8CJ"jh7CJUaJmHnHu#jhOGoh7CJUaJhOGoCJaJjhOGoCJUaJ hd85CJhYmhDQ/5CJ hDQ/CJhC'{hDQ/5hC'{hh.`5CJaJhC'{hDQ/5CJaJhC'{hC'{5CJaJhC'{h?5CJaJ h%~CJ hJCJhd8hJ5CJhd8hd85CJ hd8CJ`bd: < N P R b d v x ~ gdr gd|m gdKdhgd?$a$gdd8gdd8J?KAKK  ( * , 6 8 < H J L N b d f p r v ~ 𻱫yqe]K#jRhC'{hzCJUaJh @ J L ȶӤȒӤzk`Nkk#jhC'{hzCJUaJhC'{hCJaJjhC'{hCJUaJ hd8CJhh/hJ5CJhd8CJaJ#jLhC'{hzCJUaJ"jh7CJUaJmHnHu#jhC'{hzCJUaJhC'{h D N R T h j l p r v | Ժԓԓoԓe_ hCJhh/h5CJ#jhC'{hCJUaJ#jhC'{hCJUaJh5CJaJ#jhC'{hCJUaJhh/h5CJaJhCJaJ"jh7CJUaJmHnHujhC'{hCJUaJ#jhC'{hCJUaJhC'{hCJaJ%    " $ ( * 4 6 : < P Լy“smcsmWOhh/CJaJjhh/CJUaJhh/hYm5CJ hd8CJ hYmCJ#jThOGoh7CJUaJhOGoCJaJjhOGoCJUaJ hd85CJhYmh%~5CJ hh/CJ hrCJ hCJ"jh7CJUaJmHnHujhC'{hCJUaJ#jhC'{hzCJUaJhC'{hCJaJP R T ^ ` b d p t v ùϤsaϤXsh5CJaJ#jhC'{hCJUaJhh/h5CJaJhCJaJ#j(hC'{hCJUaJhC'{hCJaJjhC'{hCJUaJ hCJhh/h5CJ hrCJ h%~CJ"jh7CJUaJmHnHujhh/CJUaJ#jhh/h\UJCJUaJ       ( * , 6 8 : < H N P d f h r t v x | ~ ÷ޤïޤpނjd]QhC'{hr5CJaJ hr5CJ h%~CJ hrCJ#j hC'{hzCJUaJ hCJhh/h5CJ#jhC'{hCJUaJhC'{hCJaJhCJaJhh/h5CJaJh5CJaJ"jh7CJUaJmHnHujhC'{hCJUaJ#j$hC'{hCJUaJ   $&:<>HJNdfjlŹ~sa~~~s#j hC'{hh.`CJUaJhC'{hh.`CJaJjhC'{hh.`CJUaJ"jh7CJUaJmHnHu#jt hOGoh7CJUaJhOGoCJaJjhOGoCJUaJ hh.`CJhh/hr5CJ hrCJhC'{hh.`5CJaJhC'{hr5CJaJhC'{hC'{5CJaJ LN(&'9_Nx & F hx^`gd} & F h*x^`gd} & F hx^gd}gd"zgdrdhgdr gd}$&(*,6LƼƶ̧Ƽ~Ƨļb[b[b[b hr6CJhrhr6CJ#jN hC'{h9CJUaJ hh/CJ hCJ#j hC'{h9CJUaJhC'{h}CJaJjhC'{h}CJUaJ hh.`CJhh/hr5CJ hrCJ"jh7CJUaJmHnHujhC'{hh.`CJUaJ#j\ hC'{hh.`CJUaJ" %&'89:HIJ_ǾtkbYIj@ h7h7CJUh#h"zCJh|mh"zCJh|mh}CJj h7h7CJU hh.`CJjhh.`CJU h"zCJh}h"z56CJh}h56CJh}h 56CJhC'{hJCJhC'{h%~CJaJhC'{hh.`5CJaJhC'{hC'{5CJaJhC'{hr5CJaJhr5CJaJ_`nopr $NO]^_xyнuejh7h7CJUjh7h7CJUj h7h7CJU h6CJ h CJ h"zCJj( h7h7CJU hh.`CJjhh.`CJUh}hzG|CJh}h"zCJj h7h7CJUh}hh.`CJjh}hh.`CJU&ABJ{Lthjvwżߕ߭~uh5CJaJ h"zCJ hi9dCJh5shYmCJaJ hss<CJ hC'{CJ hYmCJ hCJ hi9dCJhC'{hi9daJhC'{hC'{aJhz@CJaJhh.`h CJhh.`hCJ h CJjhh.`CJUjh7h7CJU+BC}~{|IJOPgh`gdss< & Fgdi9dgdi9d$a$gdi9d & F hx^gd}hvwHHIIII%J&J'J gdss<dhgdss<gdss<gdss<gd@#gh^hgd6gdi9d`gdss<HHHIIYJZJ[J\JlJmJoJpJJJJJJJJJJJJJǩǙulbWuQ hh.`CJhCJmHnHujhh.`CJUhd8hh.`CJjhd8hh.`CJUhh.` hh.`CJjlh1?hh.`CJUjhh.`CJUmHnHu h"eCJ h"e6CJh"eh"e6CJ h%~6CJ h%~CJhss<h"e5CJhss<hss<5CJU hss<5CJ hss<CJ h CJh@#g5CJaJCOUNTY OF JEFFERSON I, the undersigned Notary Public in and for the Commonwealth and County of aforesaid, do hereby certify that the foregoing instrument was this day presented to me by _________________________ being the authorized representative of _________________________________, who being by me first duly sworn, declared that he/she signed the foregoing instrument as his/her true and proper act and deed. Witness my hand this ________ day of __________________________, 2005. My Commission Expires: ____________________________________ __________________________________ NOTARY PUBLIC For MSD use only: Division of Water Approval Received __/__/____   FILENAME Application_Approval.dot Form Rev. 7/13/2007 Page  PAGE 1  FILENAME Application_Approval.dot Rev. 6/14/2007 Page  PAGE 3  Record Number ____________ MSD USE ONLY Record Number ____________ MSD USE ONLY 'JKJZJ[J\JnJoJpJJJJJJJJK7K8K=K>K?K@KAKgdz@L`Lgd|mgd" &dPgd" gdss< gdss<JJJJJJJJJJJJJJJJKK,K-K3K4K5K6K7K8K9K:KK?K@KAKBK]KjKɼޚysoke^ hh.`5CJ hh.`CJhJh7 hz@CJjJh1?hz@CJUjhz@CJUmHnHuh9hz@hCJmHnHujhz@CJUhd8hz@CJjhd8hz@CJUhh.`h70JmHnHu hz@0Jjhz@0JU hz@CJ hOGoCJ hh.`CJ hC'{CJ$AKBK]KjKkKlKmKKKKKKKgd"$a$gdh.`gdh.` jKlKmKKKKKK h%~CJhz@ hz@5CJ hz@CJ hz@CJhh.`*&P:p K/ =!"#$%- 0&P:p K/ =!"#$%- 0&P:p K/ =!"#$%jDjD~D TITLE CASE~D TITLE CASE|D UPPERCASEjDjD~D TITLE CASEjD~D TITLE CASE~D TITLE CASE|D UPPERCASEjDjDjDjD~D TITLE CASE~D TITLE CASE|D UPPERCASEjDjDjD~D TITLE CASE~D TITLE CASEtD#,##0~D TITLE CASEtDeCheck1tDeCheck2tDeCheck3tDeCheck4tDeCheck5tDeCheck6tDeCheck7tDeCheck8 DdX (#x <  C AbN 0,f.1x5Z* =n" 0,f.1x5ZPNG  IHDRXgAMAPLTEٟ pHYs+ IDATxn`FEt!_@/YkQZvs `D |mc  |i'bv72rma$E"E('Nzg_[U7If$eIbI{dUѵY4ES>#{INuiRBSѾrV.XUQ}}є&hO g5Π^gϪKD(`򉰊-T$͛uEP]=U\$p^4˱jֱf]YS4;\mڏE.,Rtճiw.j(jО)nWYbGlt|Mb9! 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