SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES
OFFICE OF WASTEWATER MANAGEMENT
360 YAPHANK AVENUE, SUITE 2C, YAPHANK, NY 11980
(631) 852-5700 | Healthwwm@suffolkcountyny.gov
FOR OFFICE USE ONLY
Health Department Ref. No.
Application Checklist for
Realty Subdivision and Development
(Please Type or Print the Following Information)
Name of Proposed Subdivision or Development:
Hamlet
Town
Tax Map No.
District(s)
Section(s)
Block(s)
Lot(s)
Name of Applicant(s):
Name of Design Professional:
S.C. Groundwater Management Zone:
Required Material
General Material
Y
N/A
Y
N/A
Completed application form for Approval of Realty
Subdivisions and Development (Form WWM-023)
For non-exempt maps w/ existing structures,
certification of existing sanitary system and water
supply (If system does not comply with standards an
upgrade application must be submitted)
Four (4) prints of the realty subdivision or development
map
Yield map (20,000 sf or 40,000 sf lots)
Completed S.C. short environmental assessment form
with original signatures
Copies of existing covenants or easements
NYS certificate of authorization or disclaimer
Copies of road abandonments
Coordination Material
Y
P
N/A
Comments/Explanation
SEQRA determination from the Town/Village
Planning Board/Zoning approval from the Town/Village
Water availability Letter from the water district
Sewer district sewer availability letter (other than SCDPW)
SCDPW Sewer District Availability letter
SCDHS Pollution Control approval for sanitary abandonment
(required when abandoning
commercial/industrial sanitary
systems as part of the subdivision)
Schedule test well sample with the SCDHS Water Quality Unit
NYS DEC wetlands permit
Town/Village wetlands permit
Board of Review variance application for proposals exceeding
SC Sanitary Code Article 6 density or not meeting construction
standards
For proposals exceeding density, A letter attached to the
application indicating the proposed means to offset density
(TDR, Pine Barrens Credits, etc.)
Completed Transfer of Development Rights (TDR) Data Sheet
with required documents (Form WWM-121) if TDR proposed
Application submitted to upgrade existing sanitary and water
supply (Use application form WWM-057)
WWM 203 (4/15) Page 1 of 2
Map Information
Y
N/A
Y
N/A
Location of existing structures, sanitary systems, and
water supplies depicted and labeled (indicate if none)
For Residential subdivision typical dwelling with
sanitary and water supply depicted on each lot
Label sanitary systems, water supplies, or structures
that are to be removed
Typical lot layout depicted
Metes and Bounds of proposed lot lines
Drainage shown in flag lot driveway or common
driveways
Tax map number stated
Water easement area labeled
Lots labeled (i.e. Lot 1, Lot 2, etc.)
Water lines shown for flag lots
Lot areas
For high groundwater typical sanitary profile with
invert and grade elevations depicted
North arrow and Key map
Test Hole location/ data/ elevation/date/company
depicted
Scale (Engineering scale)
Soil classification based on unified soil Classification
system
SCDHS approval stamp language
Groundwater and highest expected groundwater
elevation stated
Neighboring water supplies stated (public water,
private well, vacant) for all lots within 150ft of the
subdivision
Corner elevations stated or 2ft contours
Location of neighboring wells depicted for all lots
within 150ft of the subdivision
Elevations based upon NAVD (1988), USC & GS Datum
Location of existing and/or proposed water mains
For private wells, test well location depicted and
labeled
Location of existing and/or proposed sewer mains
For private wells, well detail depicted
Location of surface waters/wetlands within 300ft of
the property depicted
Land Surveyor original signature and seal
(Either the seal or signature must be original)
For commercial subdivisions, allowable flow calculation
stated for each lot
Design professional statement on the plan and signed
For commercial subdivisions with existing buildings,
existing sanitary flow calculations provided
Design professional original signature and seal
(Either the seal or signature must be original)
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.
APPLICANTS SIGNATURE(S), (AGENT, ETC. NOT ACCEPTABLE) ________________________________________________ DATE __________
PRINT APPLICANTS NAME (S) _________________________________________________________________________________
DESIGN PROFESSIONALS SIGNATURE _________________________________________________ DATE ____________________
PRINT NAME ___________________________________________________________________ LICENSE # _________________
WWM 203 (4/15) Page 2 of 2
click to sign
signature
click to edit
click to sign
signature
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