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NEW YORK STATE DEPARTMENT OF HEALTH DEPARTMENT OF ENVIRONMENTAL CONSERVATION APPLICATION FOR APPROVAL OF SANITARY FACILITIES FOR REALTY SUBDIVISIONS NOTE: (Law requires that no subdivision or portion thereof shall be sold, leased or rented or any permanent building erected thereon until plans are approved by State Department of Health or Department of Environmental Conservation.) Application is hereby made for the approval of plans for realty subdivision as required by the provision of Title 11 of Article 11 of the Public Health Law, and Title 15 of Article 17 of the Environmental Conservation Law. GENERAL INFORMATION 1. Name of (Village or Town) 2. (State name of person, company, corporation or association, owning the subdivision) 3. Business City 4. (if organized, give names of officers) 5. Total area of entire of this Total number of of lots in this Have plans for previous section been Will plans for additional section be 6. Do you intend to build houses on this subdivision?_____________Do you intend to sell lots Do you intend to build on some lots and sell others without 7. Is this subdivision or any part thereof located in an area under the control of local planning, zoning or other If so, have these plans been submitted to such Have these plans been approved or disapproved by such governing 8. Nature of (Describe to a depth of 10 feet (20 feet if seepage pit are proposed) give thickness of strata such as topsoil, clay whom loam, sand gravel rock, etc.) How determined____ 9. (State whether ground is flat, rolling steep or gently slope, etc.) 10. Grading: state depth of maximum ---PAGE BREAK--- 11. Depth to water table whom (give maximum and minimum If there is any variation) How WATER SERVICE 12. Proposed method of supply (If public supply, give name of municipality, water district of company) Has municipality, district or company agreed to supply 13. State approximate distance to nearest public water supply main of municipal 14. State approximate distance to nearest subsurface disposal 15. If a water supply application is required, has the approval from Bureau of Water Regulation, Department of Environmental Conservation been SEWERAGE SERVICE 16. Proposed method of collection and disposal of (Give name of municipality or sewer district if public sewers are to be used) Has municipality, district of company agreed to provide sewerage 17. State approximate distance to nearest public sewer main of municipal (Give name of municipality or sewer district) 18. State approximate distance to nearest well water DRAINAGE 19. Are there any low or wet areas that require (yes or no) Are there any watercourses, ditches, ravines which may be filled (yes or no) Is there an existing local drainage plan?_________Have these plans been approved by drainage officials?_____ Provision for surface drainage should be shown on plans. GAS TRANSMISSION LINES 20. Does a high pressure gas transmission line pass through or within 300 feet of any lot in this subdivision?______ If so, has its location been show accurately upon ADDITIONAL INFORMATION 21. Maximum number of bedrooms in completed house______________Bedrooms in expansion 22. Cellar drainages: Are cellar or footing drains to be If so, show on plans how drainage will be disposed of. 23. Laundry wastes: Are laundry tubs to be located in If so, show on plans how waste will be disposed of. ---PAGE BREAK--- It is hereby agreed that if the attached plans or any amendment or revision thereof, are approved by the State Department of Health or State Department of Environmental Conservation, installation of water supply and sewage disposal facilities will be make in accordance with the details thereof as shown on such approved plans. If the subdivided land, shown on such plans are sold before such installations are made, it is agreed that all purchases of lots will be furnished with a legible reproduction of the approved plans and they will be notified of the necessity of making such installations in accordance with such approved plans. OFFICIAL The Statement must be signed by the owner of the land platted for subdivision or the responsible official of the company of corporation offering the same for sale. TO BE FILLED IN BY PROFESSIONAL ENGINEER OR LAND SURVEYOR* The plans submitted with this application were prepared by me or under my supervision and direction. Individual water and sewerage systems, if shown on plans, were designed after careful and thorough study of local geological and existing sanitary condition. Name(give Firm, if License and *Land surveyor only if granted exception under Section 7208n of the State Education Law *Please see fee schedule for fee payment. H.D.GEN 157 (REV.2/09)