Form HD-1 "Application for Approval of Plans for a Wastewater Disposal System" - DUTCHESS COUNTY, New York

What Is Form HD-1?

This is a legal form that was released by the Department of Behavioral & Community Health - Dutchess County, New York - a government authority operating within New York. The form may be used strictly within DUTCHESS COUNTY. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 1996;
  • The latest edition provided by the Department of Behavioral & Community Health - Dutchess County, New York;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a printable version of Form HD-1 by clicking the link below or browse more documents and templates provided by the Department of Behavioral & Community Health - Dutchess County, New York.

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Download Form HD-1 "Application for Approval of Plans for a Wastewater Disposal System" - DUTCHESS COUNTY, New York

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DUTCHESS 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? _____
DUTCHESS 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? _____
26.
Has application been submitted to local NYSDEC office? _____
27.
Is any portion of this project located within a designated wetland? _____
28.
Is a Wetland Permit required? ___
29. Has application been made to local DEC office? ___
30.
Does project require a Stream Disturbance Permit? ___
31.
Is project located within 1000 feet of existence of abandoned landfill, hazardous waste site, salt
stockpile or any other potential known source of contamination? _____
Describe: _________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
32.
Does this project involve discharge or storage of industrial or hazardous wastes? _____
Describe: _________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
33.
Is there a local master plan on file with the Town, Village, City? _____
34.
Are community water, sewer facilities planned to be developed within 15 years? _____
35.
Are any sewage disposal areas in excess of 10% slope? ____
36.
Tax Map I.D. Number: ____ - _______ - ____ - ____________
37.
Approved plans are to be returned to: ___ Applicant
___ Engineer
If the application is signed by a person other than the applicant shown in Item 1, the application must be ac-
companied by a letter of authorization. Failure to comply with this provision may be grounds for the
re-
jection of any submission.
I hereby affirm, under penalty of perjury, that information provided on this form is true to the best of my
knowledge and belief. False statements made herein are punishable as a Class A Misdemeanor pursu-
ant to Section 210.45 of the Penal Law.
Signatures and official titles: _____________________________________________________________
_____________________________________________________________
Mailing address:
_____________________________________________________________
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