Application For Approval Of Plans For A Wastewater Disposal System Form
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2DUTCHESS COUNTY DEPARTMENT OF HEALTH
APPLICATION FOR APPROVAL OF PLANS FOR A WASTEWATER DISPOSAL SYSTEM
1.
Name & address of applicant: _________________________________________________________
__________________________________________________________________________________
2.
Name of Project: ___________________________
3. Location: T/V/C ______________________
4.
Project Engineer ____________________________
5. Address ____________________________
_________________________________
6.
Type of Project ___ Private/Residential
___ Camp
___ Commercial
___ Apartments
___ Institutional
___ Mobile Home Park
___ Office Building
___ Food Service
___ Other (specify) _______________________________
___ Realty Subdivision
7.
Is this project subject to State Environmental Quality Review (SEQR)?
Type status (check one)
___ Type I
___ Type II
___ Exempt
___ Unlisted
8.
Is a Draft Environmental Impact Statement (DEIS) required? _____
9.
Has a DEIS been completed and found acceptable by the Lead Agency? _____
10.
Name of Lead Agency: _____________________________________
11.
Is this project in an area under the control of local Planning, Zoning or other officials, ordinances? ____
12.
If so, have plans been submitted to such authorities? _____
13.
Has preliminary approval been granted by such authorities? _____
14.
Type of sewage disposal system discharge: ___ Surface waters
___ Ground waters
15.
If surface water discharge, what is the stream class designation? ______________________________
16.
Waters index number (surface) ________________________
17.
Is project located near a public water supply system? _____
18.
If yes, name of water supply: _________________________ Distance to water supply: ____________
19.
Is project site near a public sewage collection or disposal system? _____
20.
Name of sewage system: ____________________________ Distance to sewage system: _________
21.
Were subsurface soil tests observed by a Health Department representative? _____
22,
Date observed: __________________ 23. Name of Health Inspector: _________________________
24.
Project design flow (gallons per day) ______________________
25.
Is an application for State Pollutant Discharge Elimination System (SPDES) required? _____
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