Fillable Limited Septic Registry Instructions (Town of East Hampton)

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Limited Septic Registry Instructions (Town of East Hampton)

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U.S.A. forms for Town of East Hampton

BROWSE TOWN OF EAST HAMPTON (NY) FORMS

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Page 1 of 3
Town of East Hampton
300 Pantigo Place, Suite 104
East Hampton, NY 11937
Phone: 631-324-4145 Fax: 631-329-5739
Limited Septic Registry Instructions
Applicability:
Limited Septic Registry must be completed for the installation of low-nitrogen septic systems as
approved by Suffolk County Department of Health Services (SCDHS) for the replacement or
upgrade of existing sanitary systems without any increase in capacity or any proposed change of
use of the premises upon which the system is located.
Instructions:
1. Application must be completed and submitted, in duplicate, to the Town of East Hampton
Building Department.
2. Include a copy of approved Suffolk County Department of Health Permit (Red Stamp) to
include location of existing and proposed new system on survey/plans and description of
proposed work.
3. Upon receipt of this application, the Building Inspector will issue a Limited Septic Registry to
the applicant, such registry shall be kept on the premises, available for inspection throughout the
process of the work.
4. Inspections to be completed by Suffolk County Department of Health. It is the applicant's
responsibility to file, get approvals and inspections, as required by SCDHS.
5. Contact the Town of East Hampton Natural Resources Department at 631-324-0496 to notify
of system installation for TOEH Septic Incentive Program installations, if applicable.
6. Green stamped final approval SCDHS required for close out of permit and receipt of
certificate of compliance.
7. All construction must be designed to keep water runoff on the property.
8. Electrical Underwriter Certificate and location of electrical control panel required.
Page 2 of 3
Application for Limited Septic Registry
Owner Information:
Owner Name (titled owner of property): ____________________________________________________
Home Address: _______________________________________________________________
Mai
ling Address: _______________________________________________________________
Telephone #: _______________________ E-mail:_________________________________
Location of where work will be performed:
Date:
Application #:
Registry #:
________________
________________
________________
Town of East Hampton
300 Pantigo Place, Suite 104
East Hampton, NY 11937
Phone: 631-324-4145 Fax: 631-329-5739
Site Address: __________________________________________________________________
Suffolk County Tax Map#: District _______ Section_______ Block______ Lot __________
Description of work to be performed: ______________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Type of Water Source: Water Well __________ Public Water Supply ___________
Sanitary System in Wetlands Jurisdiction? YES/NO,
If Yes, Existing _______ Proposed New _______
Emergency repair? YES/NO, Describe failure: _______________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Licensed Sanitary Contractor Report (to be filled out by Installer)
Install Contractor Company: _____________________________________________________________
Installer Contact Person: ____________________________ Phone #: ___________________________
Installer Contractor’s Address ___________________________________________________________
Service Contractor Company ____________________________________________________________
(Provide copy of service contract, if applicable)
Service Contact Person _____________________________ Phone #: ____________________________
Description of Low-Nitrogen System Installed:
Manufacturer/Model: ______________________________________
System Size (# Bedrooms): ______________________________________
Leaching Structure: Number of ______________ Size _______________ Depth ___________________
Type Description______________________________________________________
Covering : Slab____________ Traffic Bearing _____________ Dome _________________
Pump Out of Existing System: _____________________________________
Existing System to be Abandoned or Removed? _____________________________________
Select One
Select One
Required Attachments and License Information:
Attach copy of Suffolk County DHS Permit with survey or plans showing proposed location
Attach copy of NYS DEC Permit and/or Town NRSP Wavier (if applicable)
Attach Workers Compensation Certificate Expiration Date: ____________________
TOEH Contractor License # _________________________
Expiration Date: ______________________
Electrical License # ___________________________________
Consumer Affairs Liquid Waste License Number # ________________________________
This report from the licensed sanitary contractor that the sanitary system meets Town, County and State
codes for all other repairs, upgrades, replacements and new systems.
Installer/Contractor Signature ______________________________________ Date ________________
Application is hereby made to the Building Department for the issuance of a registry pursuant to the
Building Ordinance of the Town of East Hampton, County of Suffolk, New York and all other applicable
laws, ordinances, or regulations. The applicant agrees to comply with all applicable laws, ordinances and
regulations.
Signature of Applicant: _____________________________________________
Town of East Hampton
300 Pantigo Place, Suite 104
East Hampton, NY 11937
Phone: 631-324-4145 Fax: 631-329-5739
Page 3 of 3
(Leave area below blank)
Building Department Notes Section:_______________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Permit Mailing Address (the Building Department will mail the permit to this address):
____________________________________________________________________________
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Limited Septic Registry Instructions (Town of East Hampton)

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Completed 13 February 2021

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