Location of existing structures, sanitary systems, and
water supplies depicted and labeled
Location of proposed structures, sanitary systems, and
water supplies depicted and labeled
Metes and Bounds of property lines
Gross floor areas of existing/proposed buildings
Number of stories of each building w/ dimensions and
finished 1
st
floor elevation, including basement
Label sanitary systems, water supplies, or structures
that are to be removed
Scale (Engineering Scale)
Indicate occupant and use of each building and/or unit
Groundwater management zone
Allowable flow calculation
Distance to the nearest cross street
Existing and proposed sanitary flow calculations
provided
5x7 clear space for approval stamp
Design calculations sizing the existing and/or proposed
sanitary system
Design professional signature and seal
(Either the seal or signature must be original)
Details of septic tank/grease trap/leaching pools/
manholes/ pump station/crossings
Design professional title block
50% leaching pool expansion area
Test hole location/ data/ elevation/date/company
depicted
Profile of sanitary system/sewer mains with inverts and
grade elevations
Soil classification based on unified soil classification
system
Setbacks maintained in accordance w/ Table 2 of the
commercial standards
Elevations based upon NAVD (1988), USC & GS Datum
Details of water supply systems (thrust blocks, RPZ,
private well details)
Groundwater and highest expected groundwater
elevation stated
Location of underground storage tanks
Corner elevations stated and/or 2 ft contours
Retaining wall detail w/ elevations
Neighboring water supplies stated (public water,
private well, vacant) for all lots within 150 ft of the
Location of drainage structures (existing and proposed)
Location of neighboring wells depicted for all lots
within 150 ft of the property
Location of existing and proposed utility lines
(gas/electric)
Location of existing and/or proposed water mains and
service lines
Location of existing/proposed easements labeled
Location of existing and/or proposed sewer mains and
house connections
Location of surface waters/wetlands within 300 ft of
the property depicted
Additional Comments/Explanations:
APPLICATION IS HEREBY MADE FOR A PERMIT IN ACCORDANCE WITH THIS APPLICATION, SURVEY(S) AND PLAN(S) SUBMITTED. WE CERTIFY THAT THE
INFORMATION ON ALL THE PAGES OF THIS CHECKLIST AND ALL THE ATTACHMENTS HAVE BEEN REVIEWED BY US AND THAT, BASED ON OUR INQUIRIES, SITE
INVESTIGATION(S) AND/OR OTHER STUDY(IES), WE BELIEVE THAT THE INFORMATION IS TRUE, ACCURATE AND COMPLETE. WE UNDERSTAND THAT FALSE
STATEMENTS MADE HEREIN ARE PUNISHABLE AS A CLASS A MISDEMEANOR PURSUANT TO SECTION 210.45 OF THE PENAL LAW.
APPLICANT’S SIGNATURE(S), (AGENT, ETC. NOT ACCEPTABLE) ______________________________________________ DATE ____________
PRINT APPLICANT’S NAME (S) _________________________________________________________________________________
DESIGN PROFESSIONAL’S SIGNATURE _________________________________________________ DATE ____________________
PRINT NAME _______________________________________________________________ LICENSE # _____________________
WWM –201 (4/15) Page 2 of 2
click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
![]()
