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Narrowsburg Sewer District APPLICATION FOR SEWER SERVICE ITEMS TO BE INCLUDED WITH THE APPLICATION: 1. SIGNED AND NOTARIZED EASEMENT FOR EACH PROPERTY THE PROPOSED SEWER CROSSES.(NEED DISTRICT FORM EASEMENT) 2. A NYS TRANSFER GAINS AFFIDAVIT, SIGNED AND NOTARIZED BY PROPERTY OWNER(S) AND EASEMENT OWNER(S).(NEED NYS FORM) 3. A TOWN/COUNTY OR SCHOOL TAX BILL FOR THE LOT THAT IS REQUESTING A HOOKUP. 4. APPLICATION FEE: RESIDENTIAL/TWO-FAMILY - $
75.00 6. FLOOR PLAN DATE__________________ APPLICANT NAME_________________________________________________________ ADDRESS______________________________________________________________________ TELEPHONE____________________ TAX MAP SECTION______BLOCK______LOT______ SERVICE TYPE: SINGLE FAMILY___ TWO-FAMILY___ MULTI-FAMILY ___ COMMERCIAL___ OTHER:___ INSTALLING CONTRACTOR: NAME_________________________________________________________________________ ADDRESS______________________________________________________________________ TELEPHONE_____________________________ OWNER: NAME_________________________________________________________________________ ADDRESS______________________________________________________________________ TELEPHONE_____________________________ PAGE 1 OF 2 ON AVERAGE DAY_____ ON MAXIMUM DAY_____ IF FOOD ESTABLISHMENT, NUMBER OF SEATS_____ WASTE CHARACTERISTICS: GREASE/OIL_____ PHOTOGRAPHY/X RAY_____ PRINTING_____ SAND/GRIT_____ CAR WASH_____ MEDICINE_____ LAUNDROMAT_____ CHEMICALS (SPECIFY)_____ INDUSTRIAL_____ BLOOD/BLOOD PRODUCTS_____ PAINTS/THINNERS_____ OTHER______ PETROLEUM PRODUCTS_____ FOOD ESTABLISHMENT_____ INDICATE BELOW OR ATTACH A PLAN OR SKETCH OF THE
PROPOSED BUILDING SEWER, TANK LOCATION, ALL FITTINGS, CLEANOUTS AND CONNECTION
TO DWELLING, SHOWING MATERIAL, LENGTHS, DIAMETERS, DIMENSIONS, SLOPE AND ROUTE. THE UNDERSIGNED, AS OWNER OF THE
BUILDING/DWELLING TO BE CONNECTED TO THE NARROWSBURG SEWER DISTRICT AGREES TO
ABIDE BY APPROVED CONSTRUCTION PRACTICE SUBJECT TO APPROVAL OF THE OFFICIALS OF
THE TOWN OF TUSTEN AND ALL APPLICABLE RULES, REGULATIONS AND ORDINANCES
GOVERNING THE CONNECTION DESCRIBED INCLUDING ALL AMENDMENTS THERETO. I AFFIRM
UNDER THE PENALTY OF PERJURY THAT ALL THE INFORMATION ABOVE IS CORRECT TO THE
BEST OF MY KNOWLEDGE AND BELIEF. APPLICANT/OWNER
SIGNATURE:__________________________________ DATE:__________________ The Narrowburg Water and Sewer Districts prohibit discrimination on the basis of race, color, national origin, sex, religion, age, disability, political beliefs, marital or familial status. Complaints of discrimination may be filed with the Tusten Town Supervisor at 210 bridge Street, Narrowsburg NY 12764 or by calling (914)252-7146.The Narrowburg Water and Sewer Districts are equal employment opportunity employers. Approved by Tusten Town Board 4/9/01. |
