1. INSTRUCTIONS FOR FILING COMBINED
  2. APPLICATION FOR REIMBURSEMENT FOR ENFORCING
    1. FOR APPLICATION YEAR ENDING December 31, 20  
  3. Applicant:        County:       

 

 

 

 

 

 

 

 

Combined

Application for Reimbursement

for Enforcing The Pennsylvania Sewage Facilities Act

and

Onlot Sewage Disposal Program Annual Report

 

 

 

 

 

 

 

 

 

                 
For more information, visit www.dep.pa.gov
3850-FM-BCW0280 Rev. 1/2018
INSTRUCTIONS FOR FILING COMBINED

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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.
 

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 (3850FMBCW0290) 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

 

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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    
             
             
             
             
            $       

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.) $            

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.

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)
     
                         


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.

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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