Division of Environmental Protection, One Independence Hill, Farmingville, NY 11738
(631) 451-6400
Town of Brookhaven’s
Division of Environmental Protection’s
Sanitary System Review
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Applicant’s Name Applicant’s Phone
Applicant’s Address City State Zip
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Owner’s Name (if not applicant) Owner’s Phone
Owner’s Address City State Zip
___________________________ _________________________
Agent’s Name Agent’s Phone
Agent’s Address City State Zip
Project Location:
N S E W of _____________________________________, (___________),
__________________________
Street name Number
Distance from intersection
N S E W of _______________________________________________, ___________________________
Cross street name Hamlet
SCTM# 0200 _________________ ______________ _________________
Section Block Lot
For Building Department Use Only:
Project Type:
Construction of a new Residential Dwelling (one or two family).
Construction of an addition to a Residential Dwelling (original CO prior to 1987).
Construction of an addition to a Residential Dwelling (original CO 1987 or later).
Addition increases floor area 10% or more or Addition increases floor area 50% or more
increases the number of bathrooms or bedrooms
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Determined by Date
