1. Combined
  2. Application for Reimbursement
  3. for Enforcing The Pennsylvania Sewage Facilities Act
  4. Onlot Sewage Disposal Program Annual Report
      1. INSTRUCTIONS FOR FILING COMBINED
      2. APPLICATION FOR REIMBURSEMENT FOR ENFORCING
      3. THE PENNSYLVANIA SEWAGE FACILITIES ACT
      4. ONLOT SEWAGE DISPOSAL PROGRAM ANNUAL REPORT

Combined

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Application for Reimbursement

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for Enforcing The Pennsylvania Sewage Facilities Act
and

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Onlot Sewage Disposal Program Annual Report
For more information, visit
www.dep.pa.gov
3850-FM-BCW0280
Rev. 1/2018

3850-FM-BCW0280
Rev. 1/2018
COMMONWEALTH OF PENNSYLVANIA
Instructions
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF CLEAN WATER
INSTRUCTIONS FOR FILING COMBINED
APPLICATION FOR REIMBURSEMENT FOR ENFORCING
THE PENNSYLVANIA SEWAGE FACILITIES ACT
AND
ONLOT SEWAGE DISPOSAL PROGRAM ANNUAL REPORT
Read all instructions carefully before completing your application.
There have been changes to the form and requirements.
If
any of the information or supporting documentation is not submitted, you risk loss or delay of reimbursement. Questions may be
referred to 717.787.5017.
DEADLINE:
The application/annual report must be received by the Department of Environmental Protection (DEP) no later than
March 1, 2018.
You must submit your application to:
Pennsylvania Department of Environmental Protection
Bureau of Clean Water
Division of Municipal Facilities
P.O. Box 8774
Harrisburg, PA 17105-8774
COMPLETE ALL SECTIONS AS INDICATED:
SECTION A.
The local agency (LA) official must be an elected official or a person in a responsible position with the LA. The
Sewage Enforcement Officer (SEO)
cannot
be named as the official. Multimunicipal local agencies and county health departments
must attach a list of member municipalities and date of affiliation.
SECTION B.
Complete after Sections C and D are completed.
SECTION C.
a.
List only reimbursable expenses.
Reimbursable expenses include permit-related activities as well as sewage management
program (SMP) activities and malfunction and complaint investigations. These expenses
must be itemized and completely
documented
by one (1) copy of the
Activity Record for Enforcement of the Pennsylvania Sewage Facilities Act (Act)
form
(3850-FM-BCW0039) available electronically on DEP's website at
www.dep.pa.gov
or
invoices
equivalent to the activity form.
Each permit-related activity must be identified by a DEP permit application number
.
Activity records or invoices must
identify the specific person who performed each activity. Expenses under each category should be totaled in the right-hand
column under "Total Expenses," and this total should then be entered in Section B.1.
NOTE: Planning costs (costs incurred prior to approval of the planning module by DEP) and costs for soil testing
performed prior to receipt of a permit application are not eligible under the sewage facilities permitting program.
b.
One (1) copy of
proof of payment
(canceled checks, W-2 forms or payroll records) must be submitted for
all
expenses claimed
if reimbursement is requested.
If reimbursement is not requested you may omit this requirement.
Expenses which are not supported by the above documentation will not be considered for reimbursement. Your claim
for expenses must be in accordance with 25 Pa. Code §72.44, available electronically at
www.pacode.com
.
SECTION D.
The revenue from the permit fees, fines, other money and uncollected revenue (money that people owe you) is to be
totaled and entered in Section B.2. of this form.
SECTION E.
Insert the fees charged to applicants and fees charged to the municipality by the SEO for each type of permit.
Do
not
enter the total income received or paid out from these permit fees.
SECTION F.
List the names of each person appointed by the LA as an SEO. Do not list a firm.
SECTION G.
Do not modify
this table. Information must be supported by the submission of DEP's Central File copies of the
Application for an Onlot Sewage Disposal System Permit
(3850-FM-BCW0290) for every permit which was denied, final inspected
or expired during the year. The appropriate totals of Columns C, D and E must equal the number of Central File copies submitted
with the application. Be sure final action dates are indicated. Do
not
submit Central File copies of the
Application for an Onlot
Sewage Disposal System Permit
which have
not
been finalized. These copies should be submitted with the application for the year
in which the final action occurred.
SECTION H.
Completion of this Section is required if a SMP has been approved in a sewage facilities official plan or plan revision.
This Section is being used to track program activity statistics.
SECTION I.
This affidavit must be sworn to by the LA official before a notary public. The seal and signature of the notary public
must be affixed. In the case of townships of the second class, the township seal may be affixed with the official's signature in lieu
of notarization when this action has been approved by the township supervisors. The SEO
cannot
complete any part of this section.
The applications must have original signatures and seals.
IF REIMBURSEMENT OF PROGRAM EXPENSES IS NOT REQUESTED, SECTIONS A, B,
E, F, G, H (if applicable) AND I MUST STILL BE COMPLETED AND SUBMITTED.

- 1 -
3850-FM-BCW0280
Rev. 1/2018
Form
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF CLEAN WATER
DEPARTMENT USE ONLY
Date Stamp
COMBINED APPLICATION FOR REIMBURSEMENT FOR ENFORCING
THE PENNSYLVANIA SEWAGE FACILITIES ACT AND ONLOT SEWAGE DISPOSAL PROGRAM ANNUAL
REPORT
FOR APPLICATION YEAR ENDING December 31, 20
READ ALL INSTRUCTIONS BEFORE COMPLETING. APPLICATION MUST BE RECEIVED BY THE
DEPARTMENT OF ENVIRONMENTAL PROTECTION (DEP) NO LATER THAN
MARCH 1
FOR ALL DUTIES
PERFORMED FROM JANUARY 1 THROUGH DECEMBER 31 OF PRECEDING YEAR.
SECTION A
1.
Applicant (Local Agency (LA))
1.A.
Multimunicipal LA
Membership list
attached
2.
Address
3.
City
Zip
4.
Name and Title of LA Official
5.
E-mail address (optional)
6. Daytime Telephone Number
7. County
8. Federal I.D. No.
SECTION B - REIMBURSEMENT REQUEST
1. TOTAL EXPENSES
$
2. NET REVENUE
$
3. PROGRAM DEFICIT
(subtract 2 from 1)
$
4. REIMBURSEMENT REQUESTED
(This is the program deficit, shown on
Line 3, but never more than 1/2 of the total
expenses, shown on Line 1)
$
DEP USE ONLY
5. Reviewer's Initials and Approval Date
/
/
Submit your application in triplicate, 1 copy of supporting documentation (if requesting reimbursement) and
appropriate Central File copies of the
Application for An Onlot Sewage Disposal System Permit
(3850-FM-BCW0290) no later than March 1, 2018 to:
Pennsylvania Department of Environmental Protection
Bureau of Clean Water
Division of Municipal Facilities
P.O. Box 8774
Harrisburg, PA 17105-8774

3850-FM-BCW0280
Rev. 1/2018
Form
- 2 -
Applicant:
County:
SECTION C - ITEMIZED EXPENSES
Copies of activity records or itemized invoices and proof of payment for these expenses must be submitted.
COST OBJECT
AMOUNT
OBJECT TOTAL
Sewage Enforcement Officer (SEO) Expenses
$
$
Administrative & Clerical Expenses
$
Sewage Management Program (SMP) Expenses (See also Section H)
Date of Approval of Official Plan proposing SMP
$
Consultant Services
$
Materials & Supplies
$

3850-FM-BCW0280
Rev. 1/2018
Form
- 3 -
Applicant:
County:
Legal Services
$
Auto Expense
miles @
¢/mile
$
Social Security and Medicare Expense
$
Other Expenses
$
Total Expenses:
$
Enter Total in Section B.1.
NOTE: Expenses are subject to audit by DEP or its authorized representative.
SECTION D - REVENUE
1. Total Revenue from Permit Fees
$
2.
Other Money Received - specify, i.e., SMP fees,
assessments, money from municipalities and other agencies,
fines, interest, etc.
$
3. Uncollected Revenue - specify, i.e., Accounts
Receivable, to include LA assessments
to member municipalities and revenue from applicants
$
$
Total Revenue
$
Less Refunds
$
Net Revenue (Enter total in Section B.2.)
$

3850-FM-BCW0280
Rev. 1/2018
Form
- 4 -
Applicant:
County:
SECTION E - SCHEDULE OF PERMIT FEES
SEO Fees/Charges to the LA*
Permit
Application Fees
(LA Income)*
Residential
Other
Residential
Other
Permit Application
1.
Conventional
New
Repair
2.
Alternate
New
Repair
3.
Other
Site Inspection/Consultation
Evaluate Probes
Conduct Probe
Observe Perc
Conduct Perc
Review Design
Issue Permit
1.
Conventional
New
Repair
2.
Alternate
New
Repair
3.
Other
Final Inspection
1.
Conventional
New
Repair
2.
Alternate
New
Repair
3.
Other
Reissue Expired Permit Using Prior Tests and
Design
Rate for Other Work (Specify) (Hourly or Flat
Rate)
* This section must be consistent with the LA's current fee schedule.

3850-FM-BCW0280
Rev. 1/2018
Form
- 5 -
Applicant:
County:
SECTION F
List the primary and alternate SEOs for the LA. Provide dates of employment for each. (Use additional sheets if necessary.)
Primary
Alternate
Name
Name
Address
Address
Telephone
Telephone
Certificate No.
Certificate No.
Employed from
to
Employed from
to
SECTION G - SUMMARY OF PERMIT ACTIVITY FROM JANUARY 1 THROUGH DECEMBER 31 OF PRECEDING YEAR
List preceding calendar year permit activities, using the appropriate onlot sewage system classifications from
25
Pa. Code
Chapter 73. (Do not substitute or change classification categories.)
A.
Applications
Taken
B.
Permits
Issued
C.
Permits
Denied/Revoked
D.
Final
Inspections
E.
Permits
Expired
1. Residential Conventional
2. Residential Alternate
3. Commercial Conventional
4. Commercial Alternate
5. Experimental
****TOTAL****
Of those permit activities listed above, list those actions that were associated with modifying a functional
system or repairing a malfunctioning system.
1. System Modification
2. System Repair
Of those repair permit activities listed in the previous section under system repairs, list those actions where
"best technical guidance (BTG)" was used.
1. System Repair (BTG)

3850-FM-BCW0280
Rev. 1/2018
Form
- 6 -
Applicant:
County:
Status of the approved SMP (choose one)
Implemented
Under active development
Not implemented
SECTION H - SUMMARY OF SMP ACTIVITY
FROM JANUARY 1 THROUGH DECEMBER 31 OF PRECEDING YEAR
A.
Number of
Systems in
Each Category
in SMP*
B.
Operation and
Maintenance
(O & M)
Educational
Materials Sent
to Property
Owners
C.
Number of
Pumping/
Maintenance
Requirement
Notices Sent
D.
Number of
Pumping
Receipts/
Maintenance
Receipts
Received
E.
Number of
Municipal
Inspections
Performed**
F.
Enforcement
Actions Taken in
Response to
Inspections or to
Property Owner's
Refusal to
Comply with
SMP
Requirements
1.
Aerobic Treatment Tank
2.
Septic Tank
TOTAL
How many of the systems in your management area use the following means of disposal? Please enter program activity as it relates to systems
having methods of disposal listed below.
A.
B.
C.
D.
E.
F.
1.
Holding Tanks
2.
Cesspools
3.
Gravity Inground Bed/Trench
4.
Pressure Dosed Inground Bed/
Trench
5.
Non-Pressure Dosed Elevated
Sand Mound
6.
Pressure Dosed Elevated Sand
Mound/Trench
7.
IRSIS
8.
Pre-IRSIS Small Flow Spray
9.
Small Flow Stream Discharge
10.
Large Volume Community Onlot
11.
Spray > 2000 gallons per day (gpd)
12.
Other Non-Municipally Owned
Sewage Treatment Plants
13.
Non-Municipally Owned Pump
Stations, Lift Stations, etc.
14.
Other (List & Identify)
TOTAL
*
Information requested in Column A is for the total number of systems included in the SMP. Information requested in Columns
B through F is for related SMP activity during the preceding year.
** Inspections performed by a consulting firm employed by the municipality or LA must also be included in Column E.

3850-FM-BCW0280
Rev. 1/2018
Form
- 7 -
Applicant:
County:
SECTION I - AFFIDAVIT
Affidavit must be completed and signed before a notary public by the LA official named in Section A.4. In the case of townships
of the second class, the township seal may be affixed hereto with the official's signature in lieu of the seal of a notary public. Is
applicant a township of the second class? (Mark the appropriate box with an X.)
Yes
No
AFFIDAVIT
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF
I,
, being duly sworn according to law, depose and say that I am an
official of the applicant and that the information included in the application and documents submitted as a part of the application
are true and correct to the best of my knowledge and belief.
Sworn to and subscribed before me this
day of
, 20
.
Signature of Notary Public
Signature of LA Official
MY COMMISSION EXPIRES
Title
SEAL
REIMBURSEMENT APPLICATION
FOR ENFORCING THE ACT
CHECKLIST
A complete application for enforcing the Act consists of:
1.
Three copies of this completed application with the original signatures and embossed seals.
2.
One copy of activity records and/or invoices for all expenses claimed.
3.
One copy of cancelled checks (both sides), W-2 forms and/or payroll records for all expenses claimed.
4.
One copy of report of revenue received listed in Section D.
5.
One copy of all municipal ordinances, acts, regulations, or procedures used in administrating the applicant’s
SMP, for first time applications. Subsequent submissions must include a copy of any additions, deletions and
amendments made during the preceding year to municipal ordinances, acts or procedures that affect the SMP.

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