<p>Waiver Checklist – Piped Distribution (continued)</p><p>Project Name: Date: Engineer Name: AK P.E. License No.:</p><p>Use of this guide is required as a part of a separation distance waiver request between a public water system’s piped distribution and a potential source of contamination such as septic systems, sewer lines, fuel tanks, storm drains, etc. as discussed in 18 AAC 80.020 (water) and 18 AAC 72.020 (wastewater). Important: Waiver requests must be accompanied by the facility and project information forms found in the Plan Review Application (see Checklist 0.0) and a sealed engineer’s report. Note: When completing this checklist, please include where in the submittal the information is found for each submittal requirement. Please be as specific as possible (specify document name, page number, section number, paragraph, etc.). This will expedite the approval process. Regulatory Submittal Requirements Reference</p><p>1. Waiver Request: Has the engineer submitting for the waiver request sealed the 18 AAC 80.020(f)(3) engineer’s report as required for each waiver submittal? The report must clearly (A) identify the separation distance waiver(s) requested and the reason(s) the separation distance(s) cannot be met, justify the lesser distance(s), and explain how the lesser distance(s) do not threaten public health. Information outlined below should be included in the report.</p><p>2. Fee: If the request includes sanitary or storm sewer lines, how many feet of water 18 AAC 80.1910(a) main will be subject to the waiver? Has the correct plan review fee payment been (11) included? Assistance determining the fee may be obtained by downloading a blank invoice from DEC’s website at http://dec.alaska.gov/eh/docs/dw/engineering- forms/plan-review-invoice.pdf or by contacting the DEC office that will be receiving the submittal. If the plan review fee is received with the submittal and the fee calculation is incorrect, the check will be returned to the payer or be shredded per the payer’s preference. If the applicant has requested that, upon receipt of the submittal, the Department calculate the fee and send or email an invoice for payment, the submittal must include the contact information for the person, agency, or company that will be responsible for the fee payment, including their name, mailing address, telephone number, and email address. This may necessitate prior arrangement with the office receiving the submittal. A plan submittal will not be reviewed until payment is received (We have had issues with unpaid invoices). The waiver review fee required under 18 AAC 80.1910(a)(11) shall be included with all waiver requests.</p><p>3. Protective of Public Health: Is justification included showing the design, 18 AAC 80.020 (g) management, and operations of the distribution system and the potential risk(s) are protective of public health? This may include a discussion of such things as construction methods, environmental factors, proposed mitigation techniques, weld logs, and field verification notes.</p><p>Checklist No. 7.1 1 of 2 Version: 2017 Waiver Checklist – Piped Distribution (continued) Regulatory Submittal Requirements Reference</p><p>4. Waiver Type: Describe the applicable design and construction condition(s) 18 AAC 80.020 (g) identified in numbers 13 to 15 in the Distribution - Piped Checklist (Checklist Number 5.0) for which a waiver is being requested. Information should include all required separation distances and prescriptive conditions not met, their location(s), and the details of each of these conditions for sanitary sewer lines, manholes, storm sewer, etc. and water mains involved.</p><p>Note: For projects with multiple lengths of water main within 10 feet of a sewer main or multiple water/sewer main crossings, the engineer should include a summary table listing each instance where the horizontal distance or prescriptive conditions at crossings are not met. The table should include the location (i.e. station) and a description of how each of the conditions (horizontal installations or crossings) is met for those locations.</p><p>2</p>