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SECTION 1 APPLICATION FOR SEWAGE DISPOSAL FACILITIES AND (Suffolk County Government)

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WWM-004 (Rev. 07/14) Page 1 of 4
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 SEWAGE DISPOSAL FACILITIES AND WATER SUPPLY SYSTEMS
FOR OTHER THAN SINGLE FAMILY RESIDENCES
This application is for (check all that apply):
[ ] New Construction
[ ] Addition to Building
[ ] Extension of Existing Permit
[ ] Food Establishment
[ ] Change in Use
[ ] Renewal of Expired Permit
[ ] Other
Briefly Describe the Proposal And Use(s) of Building:
SECTION 1
Business or Facility Name:
Hamlet
Town
Property Location: N/S/E/W side of , Feet N/S/E/W of
OR N/S/E/W Corner of and
Tax Map No.:
District(s)
Section(s)
Block(s)
Lot(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:
Name of Industrial Park, Subdivision and/or shopping center (if applicable):
Previous Health Department Reference No(s).
Site is currently:
Vacant
Improved
Town Zoning of
Parcel:
Occupancy Rating as
per Building Code:
Total Area of Parcel (Acres):
Topography (Flat, Rolling, Steep, etc.):
Gallons Per Day of Sewage Discharge:
Existing______________________
Proposed_____________________
Total Parking Spaces:
Existing ___________
Proposed___________
Number of Stories (in each Building):
Existing________ Proposed____________
Basement: Yes No
Mezzanine: Yes No
Total Gross Floor Area of Building(s)
(including all floors and Mezzanine areas):
Existing___________________________
Proposed__________________________
Specify Method of Water Supply:
[ ] Public [ ] Private Well
Distance To Water Main & Name of Nearest Public Water District:
Specify Method of Sewage Disposal:
[ ] Subsurface Disposal (conventional) [ ] Public Sewers
[ ] Other (explain)
Distance To & Name of Nearest Public Sewer District or Treatment Plant:
WWM-004 (Rev. 07/14) Page 2 of 4
SECTION 2
FOR EXISTING BUILDINGS AND/OR EXISTING/PROPOSED FOOD ESTABLISHMENTS
1.
Does proposal include change in use of an existing building?
Yes [ ] No [ ]
If yes, indicate previous name(s) of establishment: _____________________________________________
Type of business (medical, retail, etc.):_________________________ Date last opened: _______________
Floor Area of Proposed Business: _____________________ Date Building Constructed:_______________
2.
Is proposed tenant space an existing or proposed food establishment?
If yes, indicate seating below.
Yes [ ] No [ ]
Type of Seats
Bar
Restaurant
Catering
Outdoor
Number of Seats Permitted in Previous Establishment
Number of Seats in Proposed Establishment
SECTION 3
FOR HAZARDOUS MATERIAL STORAGE OR DISCHARGE
YES
NO
1.
Is or will wastewater, other than sewage, be discharged into the ground?
If yes explain
2.
Is or will oil be stored for heating purposes?
If yes, indicate the number , size of oil tank(s) in gallons & year installed
3.
Does the business (es) require process tanks or petroleum storage tanks such as
gasoline, kerosene, diesel, gasohol, motor oil, antifreeze, or waste oil?
If yes, indicate number aboveground & number underground
Indicate materials that are being stored
4.
Does or will the business (es) have more than 250 gallons of drum storage?
If yes, indicate number of drums and amount of gallons
5.
Does or will the business (es) have collection sumps, troughs, floor drains, boiler
drains, etc.?
If yes explain
6.
Does or will the business (es) involve any manufacturing processes or use of any
chemicals?
If yes explain
If the answer to any of the above questions in section 3 is yes, then permit(s) for hazardous material storage or
discharge may be necessary in accordance with Article 7 and 12 of the Suffolk County Sanitary Code and a separate
report may be required. Contact the Office of Pollution Control (631) 854-2501.
SECTION 4
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
e. SPDES-D Permit, sanitary waste only - SCDHS/NYSDEC
f. SPDES Permit - Industrial Waste - SCDHS/NYSDEC
g. Toxic and Hazardous Materials Storage/Handling, Article 12, SCDHS
WWM-004 (Rev. 07/14) Page 3 of 4
SECTION 5
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 and/or details.
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 environmental 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:
6.
Is any portion of the subject property in a “Coastal Erosion Hazard Area” (pursuant
to 6NYCRR Part 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:
8.
Will there be an adverse effect to existing traffic patterns?
If yes, explain:
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:
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.
Will the proposed action affect any water sources, surface or groundwater quality
or quantity? Ex. Will action require:
A discharge permit
Water supply from wells with greater than 45 gpm capacity
Water use in excess of 20,000 gpd
Storage of > 1,100 gallons of petroleum or chemical products
New or expansion of existing waste treatment and/or storage facilities
12.
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?
13.
Will the project substantially affect any non-threatened or non-endangered species?
If yes, explain:
14.
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?
15.
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:
16.
Have any unique or unusual landforms been identified on site?
If yes, explain:
WWM-004 (Rev. 07/14) Page 4 of 4
17.
Does the property contain scenic views known to be important to the community?
If yes, explain:
18.
Is the subject property within 100’ of any surface water(s) or regulated wetland(s)?
If yes, show on plans.
19.
Is the parcel subject to existing covenants or restrictions?
If yes, explain:
20.
Does the project require a change in zoning or a zoning variance?
If yes, explain:
21.
Is there a public water wellfield within 1,500 feet of property boundaries?
If yes, show on plans.
22.
Could the project result in any adverse effects associated with the production,
storage, processing or disposal of solid wastes?
If yes, explain:
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:
25.
Will there be a significant adverse impact to the quality or quantity of existing or
future open space? If yes, explain:
If the answer to any of the questions in Section 5 is “YES” please explain below:
Complete Instructions for filing an application are contained in the Bulletin “Application Requirements for Sewage Disposal
Facilities & Water Supply Systems for Other Than Single Family Residences” (WWM-003). Before filing an application
with the Department, you should be familiar with the “Standards for Approval of Plans and Construction for Sewage
Disposal Systems for Other than Single Family Residences” and Article 6 of the Suffolk County Sanitary Code which
describes conditions under which applications 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”.
APPLICATION IS HEREBY MADE FOR A PERMIT 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 STUDY(IES), I BELIEVE THAT THE INFORMATION IS TRUE, ACCURATE
AND COMPLETE. I UNDERSTAND THAT FALSE STATEMENTS MADE HEREIN ARE PUNISHABLE AS A CLASS
A MISDEMEANOR PURSUANT TO SECTION 210.45 OF THE PENAL LAW.
Property Owner’s Signature
Print Name
Date
Applicant’s Signature
Print Name
Date
Design Professional’s Signature
Print Name
License #
Date
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SECTION 1 APPLICATION FOR SEWAGE DISPOSAL FACILITIES AND (Suffolk County Government)

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Completed 6 August 2020

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