Application For Approval Of Sanitary Facilities For A Realty Subdivision Form - Monroe County Department Of Public Health
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2MONROE COUNTY DEPARTMENT OF PUBLIC HEALTH
111 Westfall Road, Room 938, Rochester, New York 14620
APPLICATION FOR APPROVAL OF SANITARY FACILITIES FOR A REALTY SUBDIVISION
NOTE: (Law requires that no subdivision or portion thereof shall be sold, leased or rented or any permanent building
erected thereon until plans are approved by the Monroe County Department of Public Health)
Application is hereby made for the approval of plans for realty subdivision as required by the provision of
Article III, Realty Subdivisions, Chapter 569 of the Monroe County Code
GENERAL INFORMATION
1.
Name of subdivision________________________________________________________________ Location_____________________________________
(Town or Village)
2.
Owner ________________________________________________________________________________________________________________________
(State name of person, company, corporation or association, owning the subdivision)
3.
Business address________________________________________________________________________________________________________________
(Street)
(City)
4.
Officers _______________________________________________________________________________________________________________________
(If organized, give names of officers)
5.
Total area of entire property______________________________________________ Area of this section_________________________________________
Total number of lots ____________________________________________________ Number of lots in this Section________________________________
Have plans for previous sections been Approved_______________________________________ Disapproved_____________________________________
Will plans for additional sections be submitted? _______________________________________________________________________________________
6.
Do you intend to build houses on this subdivision?________________Do you intend to sell lots only?____________________________________________
Do you intend to build on some lots and sell others without building?______________________________________________________________________
7.
Is this subdivision or any part thereof located in an area under the control of local planning, zoning or other officials?________________________________
If so, have these plans been submitted to such authorities?_______________________________________________________________________________
Have these plans been approved or disapproved by such governing authority?_______________________________________________________________
8.
Nature of soil___________________________________________________________________________________________________________________
(Describe to a depth of 10 feet (20 feet is seepage pits are proposed) giving thickness of various strata such as topsoil, clay, loam, sand, gravel, rock, etc.)
_____________________________________________________________________ By whom determined_______________________________________
How determined______________________________________________________________ Date determined____________________________________
9.
Topography____________________________________________________________________________________________________________________
(State whether ground is flat, rolling, steep or gentle slope, etc.)
10.
Grading: state depth of maximum cut ________________________________ maximum fill____________________________________________________
11.
Depth to water table Max. _____________ Min.________________________ By Whom determined____________________________________________
(Give maximum and minimum if there is any variation)
How determined _____________________________________________________ Date determined_____________________________________________
12.
Proximity to orchard or former orchard, wastesite or former wastesite______________________________________________________________________
WATER SERVICE
13.
Proposed method of supplying water ________________________________________________________________________________________________
(If public supply, give name of municipality, water district or company)
Has municipality, district or company agreed to supply water? ___________________________________________________________________________
14.
State approximate distance to nearest public water supply main of municipal system __________________________________________________________
15.
State approximate distance to nearest subsurface disposal systems ________________________________________________________________________
16.
If a water supply application is required, has the approval from Bureau of Water Regulations, Department of Environmental conservation
been received? _________________________________________________________________________________________________________________
GEN 157, SAN72 (MCDPH 2014)
H:\Environmental Health\Staff\Engineering\Plan Review\2014 Applications\SAN 72 MCDPH 2014.docx
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