Application For Approval Of Sanitary Facilities For A Realty Subdivision Form - Monroe County Department Of Public Health Page 2
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2SEWERAGE SERVICE
17.
Proposed method of collection and disposal of Sewage _________________________________________________________________________________
(Give name of municipality or sewer district if public sewers are to be used)
Has municipality, district or company agreed to provide sewerage facilities? ________________________________________________________________
18.
State approximate distance to nearest public sewer main of municipal system _______________________________________________________________
(Give name of municipality or sewer district)
19.
State approximate distance to nearest well water supplies _______________________________________________________________________________
DRAINAGE
20.
Are there any low or wet areas that require drainage? ___________________________________________________________________________________
(yes or no)
Are there any water sources, ditches, ravines which may be filled in? ______________________________________________________________________
(yes or no)
Is there an existing local drainage plan? _____________________ Have these plans been approved by drainage officials? ____________________________
State arrangements for disposing of surface water from streets and other areas _______________________________________________________________
GAS TRANSMISSION LINES
21.
Does a high pressure gas transmission line pass through or within 300 feet of any lot in this subdivision?__________________________________________
If so, has its location been shown accurately on plans?__________________________________________________________________________________
ADDITIONAL INFORMATION
22.
Maximum number of bedrooms in completed house(s) __________________________ Bedrooms in expansion attic_________________________________
23.
Cellar drainage: Are cellar or footing drains to be installed? _____________________________________________________________________________
If so, show on plans how drainage will be disposed of.
24.
Laundry wastes: Are laundry tubs to be located in basement? ____________________________________________________________________________
If so, show on plans how waste will be disposed of.
It is hereby agreed that is the attached plans dated ___________________________________________, or any amendment or
revision thereof are approved by the Monroe County Department of Public Health, installation of water supply and sewage disposal
facilities will be made in accordance with the details thereof as shown on such approved plans. If the subdivided lands, shown on
such plans are sold before such installations are made, it is agreed that all purchasers of lots will be furnished with a legible
reproduction of the approved plans and they will be notified of the necessity of making such installations in accordance with such
approved plans.
Date __________________________ Signature_____________________________________________
Official Title _________________________________________________________________________
Statement must be signed by the owner of the land platted for subdivision or the responsible official of the company or corporation
offering the same for sale.
TO BE FILLED IN BY PROFESSIONAL ENGINEER OR LAND SURVEYOR*
The plans submitted with this application were prepared by me or under my supervision and direction. Individual water and sewerage
systems, if shown on plans, were designed after careful and thorough study of local geological and existing sanitary conditions.
Name (Give Firm, if any) _______________________________________________________________________________________
Address_____________________________________________________________________________________________________
License and No._____________________________ Signature_________________________________________________________
*Land Surveyor only if granted exception under Section 7208n of the State Education Law
GEN 157, SAN72 (MCDPH 2014)
H:\Environmental Health\Staff\Engineering\Plan Review\2014 Applications\SAN 72 MCDPH 2014.docx
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