Fillable APPLICATION FOR APPROVAL OF REALTY SUBDIVISIONS AND DEVELOPMENTS (Suffolk County Government)

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APPLICATION FOR APPROVAL OF REALTY SUBDIVISIONS AND DEVELOPMENTS (Suffolk County Government)

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  • 74 check-boxes
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BROWSE SUFFOLK COUNTY GOVERNMENT (NY) FORMS

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SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES
OFFICE OF WASTEWATER MANAGEMENT
360 YAPHANK AVENUE, SUITE 2C, YAPHANK, NY 11980
(631) 852-5700 OR HealthWWM@suffolkcountyny.gov
FOR OFFICE USE ONLY
Health Department Ref. No.
APPLICATION FOR APPROVAL OF REALTY SUBDIVISIONS AND DEVELOPMENTS
SECTION 1
Name of Proposed Subdivision or Development
Hamlet
Town
Tax Map No.:
District (s)
Section(s)
Block(s)
Name of Applicant:
Tel#:
( ) -
Mailing Address:
Email Address:
Name of Design Professional:
Tel#:
( ) -
Mailing Address:
Email Address:
Name of Current Property Owner:
Tel#:
( ) -
Mailing Address:
Email Address:
Name of Agent:
Tel#:
( ) -
Mailing Address:
Email Address:
Specify total acreage of property to be
subdivided:
Specify the total number of lots proposed:
Specify Town Zoning:
Specify Method of Water Supply:
[ ] Connect to Existing Public Water Supply
[ ] Construct Private Well Supply
[ ] Other _________________________________
Specify the distance (in feet) from the nearest water main to
the property: ______________________________________
Is a water main extension proposed? ___________________
Name of the water district____________________________
Specify Method of Sewage Disposal:
[ ] Individual Sewage Disposal Systems
[ ] Connect to Existing Public Sewers
[ ] Construct A Sewage Treatment Plant
[ ] Other (explain)
Is property partially or totally within a sewer district? ______
If yes, name of district _______________________________
If no, name of and distance to nearest district ______________
Specify Topography (e.g., flat, rolling, steep, etc.):
Specify intended use of proposed lots:
[ ] Single family residences [ ] Two family residences [ ] Multi-family residences
[ ] Commercial or industrial buildings [ ] Other
__________________________________________
Site is currently:
[ ] Vacant [ ] Improved
Specify previous use(s) of site, if any:
___________________
___________________________________________
Are any new roads proposed? ________________
If yes, are the roads to be publicly or privately
owned?
__________________________
Are any road abandonments proposed? _________
WWM-023 (Rev. 02/12) Page 1 of 4
SECTION 2
OTHER PERMITS REQUIRED
YES
NO
1.
Are any of the following permits required?
a. Wild Scenic and Recreation Rivers Permit - NYSDEC
b. Long Island Well/Water Supply Permit- NYSDEC
c. Tidal Wetlands Permit
d. Fresh Water Wetlands Permit
SECTION 3
ENVIRONMENTAL QUALITY AND HEALTH REVIEW
YES
NO
1.
Has a determination been made by any other permitting agency that this project is a
Type I action pursuant to SEQRA?
2.
Has a determination of Environmental Significance (Negative or Positive
Declaration) been issued by any other permitting agency for this project?
If yes, provide copy of determination.
3.
Is the property located within or substantially contiguous to a locally or county
designated Critical Environmental Area (CEA) pursuant to Article 8 of the
Environmental Conservation Law (ECL) and 6 NYCRR? The potential impact of
any Type I or Unlisted action on the environmental characteristics of the CEA is a
relevant area of en
vironmental concern and must be evaluated in the determination
of significance prepared pursuant to Section 617.7 of SEQR.
4.
Is the property located within the area designated Central Pine Barrens Core
Preservation Area pursuant to Article 57 of the ECL?
5.
Is the project located in an area designated as “Parkland” or “Agricultural Land”?
If yes, show area on plans and/or explain in Section 5.
6.
Is any portion of the subject property in a “Coastal Erosion Hazard Area” (pursuant
to 6NYCRR Pa
rt 505) or subject to imminent erosion or flooding? Alternatively,
could the project have the potential to cause erosion, drainage or flooding problems
on adjacent or neighboring properties?
7.
Will the completed project have an adverse effect on existing air quality, or routinely
produce odors, vibrations or operating noise which exceeds the local ambient noise
levels? If yes, explain in Section 5.
8.
Will there be an adverse effect to existing traffic patterns?
If yes, explain in Section 5.
9.
Has the property ever been used for the disposal or burial of solid waste or
hazardous waste? If yes, show area on plans and/or explain in Section 5.
10.
Are there any existing environmental factors which may affect the public health and
safety of the completed project’s occupants (for example, neighboring landfills,
petroleum spills, toxic materials, noise sources, odors, etc.)?
11.
Does the property contain any species of plant or animal life listed as rare,
threatened, or endangered by New York State, the New York State Natural Heritage
Program?
12.
Will the project substantially affect any non-threatened or non-endangered species?
If yes, explain in Section 5.
13.
Is the property substantially contiguous to, or does it contain, a building, site or
district listed on the National or New York State Registers of Historic Places?
14.
Could the project affect the community or neighborhood character or adversely
affect any aesthetic, agricultural, archaeological, or other natural
or cultural
resources? If yes, explain in Section 5.
WWM-023 (Rev. 02/12) Page 2 of 4
15.
Have any unique or unusual landforms been identified on site?
If yes, explain in Section 5.
16.
Does the property contain scenic views known to be important to the community?
If yes, explain in Section 5.
17.
Is the subject property within 100’ of any surface water(s) or regulated wetland(s)?
If yes, show on maps.
18.
Is the parcel subject to existing covenants or restrictions?
If yes, explain in Section 5.
19.
Does the project require a change in zoning or a zoning variance?
If yes, explain in Section 5.
20.
Is there a public water wellfield within 1,500 feet of property boundaries?
If yes, show on preliminary map.
21.
Is there a sewage treatment plant within 500 feet of property boundaries?
If yes, show on preliminary map.
22.
Could the project result in any adverse effects associated with the production,
storage, processing or disposal of solid wastes?
If yes, explain in Section 5.
23.
Will the property be mined?
If yes, how much:
24.
Will there be a significant adverse impact to the community’s source of fuel or
energy supply? If yes, explain in Section 5.
25.
Will there be a significant adverse impact to the quality or quantity of existing or
future open space? If yes, explain in Section 5.
SECTION 4
APPLICATION IS HEREBY MADE FOR APPROVAL TO SUBDIVIDE LAND INTO PARCELS IN ACCORDANCE WITH THIS
APPLICATION, SURVEY(S) AND PLAN(S) SUBMITTED. I CERTIFY THAT THE INFORMATION ON ALL THE PAGES OF THIS
APPLICATION AND ALL THE ATTACHMENTS HAVE BEEN REVIEWED BY ME AND THAT, BASED ON MY INQUIRIES, SITE
INVESTIGATION(S) AND/OR OTHER STUDIES, I BELIEVE THAT THE INFORMATION IS TRUE, ACCURATE AND COMPLETE.
FURTHERMORE, THE OWNER/APPLICANT AGREES THAT THE INSTALLATION OF THE REQUIRED WATER SUPPLY AND
SEWAGE DISPOSAL FACILITIES WILL BE MADE IN ACCORDANCE WITH THE DETAILS SHOWN ON THE APPROVED PLANS
AND STANDARDS IN EFFECT AT THE TIME OF CONSTRUCTION. I UNDERSTAND THAT FALSE STATEMENTS MADE HEREIN
ARE PUNISHABLE AS A CLASS A MISDEMEANOR PURSUANT TO SECTION 210.45 OF THE PENAL LAW.
Note - ALL property owners and applicants must sign this form - Additional owner and applicant signatures can be
included in Section 5 on reverse if necessary.
Property Owner’s Signature(s) __________________________________________________________________________
Print Name(s) ______________________________________________________________________ Date ___________
Applicant’s Signature(s) _______________________________________________________________________________
Print Name(s) ______________________________________________________________________ Date ___________
Design Professional’s Signature _________________________________________________________________________
Print Name _______________________________________________ License # _______________ Date ___________
Complete Instructions for filing an application are contained in the Bulletin “Application Requirements for Filing
Realty Subdivision Or Development Maps” (WWM-022). Before filing subdivision applications with the
Department, you should be familiar with Article 6 of the Suffolk County Sanitary Code which describes conditions
under which subdivision or development maps are required by this Department and the general qualifications for
approval. Copies are available from the Department or at www.suffolkcountyny.gov/health under “Documents and Forms”.
WWM-023 (Rev. 02/12) Page 3 of 4
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SECTION 5
COMMENTS/EXPLANATIONS
:
WWM-023 (Rev. 02/12) Page 4 of 4
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APPLICATION FOR APPROVAL OF REALTY SUBDIVISIONS AND DEVELOPMENTS (Suffolk County Government)

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Completed 6 August 2020

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