OSWPCA: Sunshine / Query CRAHD for DPH-required approval for Exhibit A, 9Mar2012

Text facsimile

---------------------------> Joel R. Anderson

                             13 George Drive
                             Old Saybrook CT 06475-2636
                             860 388-9858
                             oswpca.com / govtwork.org
                             9 March 2012
Mary Jane Engle, MPH, R.S., Director
Connecticut River Area Health District
455 Boston Post Road, Suite 7
Old Saybrook CT 06475

Dear Director Engle:

Re (CRAHD) Connecticut River Area Health District's application form "Exhibit A." Is Exhibit A a DPH Commissioner-approved form?

According to DPH's "Technical_Standards_2011Final_Master.pdf," Sections 19-13-B103e(c)(2)(A) and 19-13-B103e(c)(2)(B), an "Application for Permit or Approval" must "(A) Be on forms identical to Form #1 in the Technical Standards; or (B) Be on forms prepared by the local director of health and deemed by the Commissioner of Public Health as equivalent to Form #1 in the Technical Standards; ...."

Do you have the DPH Commissioner's approval for CRAHD's Exhibit A eqivalent to Form #1? If so, furnish one (1) copy of the document approving Exhibit A, dated and signed by the Commissioner. I will pay the nominal copying charge.

If you don't have the Commissioner's approval, I would like to be informed of that.
 
                             Very truly yours,


                             Joel R. Anderson
e: Exhibit A




EXHIBIT A

Connecticut River Area Health District
166 Main Street, Unit 2 Old Saybrook, CT 06475
Phone 860-661-3300 Fax 860-661-3333
Serving Old Saybrook, Clinton and Deep River

APPLICATION FOR INITIAL INVESTIGATION
AND UPGRADE OF SEPTIC SYSTEM UNDER § 173-18 ET SEQ.
CODE OF THE TOWN OF OLD SAYBROOK AND
TITLE 19 OF THE PUBLIC HEALTH CODE

Date: _________________
Owners Name: _______________   Day Time Phone: ______________
Property Address: ___________________________________________
Mailing Address (if different from above)____________________
Email Address (optional): ___________________________________
Number of Bedrooms in the structure on your property: _______
You must submit the completed application, including any revisions to the information about your property, within thirty (30) days of receipt of this application form



YOU MUST CHECK ONE OF THE FOLLOWING BOXES REGARDING CLEAN WATER FUND PARTICIPATION. CHECKING BOX A MEANS YOU WILL ACCEPT CLEAN WATER FUNDS. CHECKING BOX B MEANS YOU WAIVE CLEAN WATER FUNDS.

    Box A.     [ ]   I accept Clean Water Funds to investigate and implement upgrades as necessary on my property. By signing and checking Box A you are giving the WPCA and its agents permission to access your property for the purpose of site evaluation and soil testing. Implementation of any necessary upgrades may require construction by the Town to meet Town Ordinance requirements. I understand an assessment will be made against my property in accordance with § 7-249 et. seq. of the Connecticut General Statutes.

    Box B.     [ ]   I decline Clean Water Funds to implement and pay for upgrades to my septic/sewerage system under Town Ordinances. I will undertake to pay for and implement all required upgrades. The Director of Health or the Water Pollution Control Authority will issue an order with a schedule to implement the upgrades, as applicable.
Applicant Signature: _____________ Date: __________

Print Name ________________________________________