STEVEN BELLONE JAMES L. TOMARKEN, MD, MPH, MBA, MSW
S
UFFOLK COUNTY EXECUTIVE COMMISSIONER
WWM-061 (Rev. 3/20/19)
SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES
BOARD OF REVIEW
360 YAPHANK AVENUE, SUITE 2C, YAPHANK, NY 11980
(631) 852-5700 OR HealthWWM@suffolkcountyny.gov
APPLICATION FOR VARIANCE OR WAIVER FROM REGULATIONS OR SPECIFICATIONS
TO: Review Board Chair
I, We,_______________________________________________________________________, residing/doing
business at (mailing address)___________________________________________________________________,
request a variance [ ] or waiver [ ] from (indicate Article & Section Number) ________________________, of
the New York State/Suffolk County Sanitary Code (cross one out), and is in reference to (indicate Health Services
Reference Number, name of proposed realty subdivision /development and Suffolk County Tax Map
Number)____________________________________________________________________________________
__________________________________________________________________________________________.
Brief explanation of why variance/waiver should be granted____________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
__________________________________________________________________________________________.
Date_______________________ Signature(s)________________________________________________
_________________________________________________________
Print Name(s)________________________________________________________________________________
==================================================================================
1. TYPE OR PRINT LEGIBLY and submit completed form to the address at top of application.
2. REGARDLESS OF ANY PRIOR SUBMISSION, YOU MUST ENCLOSE WITH THIS APPLICATION
a. copy of survey for residential construction, site plan for commercial construction, or map of proposed
realty subdivision/development; and
b. copies of all pertinent paperwork (i.e., Notice of Non-Conformance or letter of rejection; estimate of cost to
extend public water, etc.).
3. SUBMIT $990 FEE by check or money order, payable to ‘Suffolk County Environmental Health’. VISA &
MasterCard are also accepted online. A non-refundable convenience fee is applied to all credit card
transactions. Fee subject to change. RETURNED CHECKS AND CREDIT CARD PAYMENTS ARE
SUBJECT TO A PROCESSING FEE.
4. YOU WILL BE NOTIFIED IN WRITING of the date, time and place for the hearing.
5. The hearing will be scheduled as soon as possible; however, all hearing schedules will be based on a first
come-first served basis.
