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Application for Residential Sewage Disposal System

2. 

3. Wyoming County Health Department
   Environmental Division
   5362 Mungers Mill Road, Silver Springs, NY 14550
   Telephone 585-786-8894

   Residential Sewage Disposal System

   Residential Sewage Disposal System

5. Reason for Permit*

   1. Initial Permit (New Build) Fee $300
   2. System Replacement (Existing Home) Fee $300
   3. Renewal of Existing Permit Fee $100
   4. Septic Tank Replacement Only Fee $125

7. Existing Permit Number

9. Owner / Applicant Name*

10. Email Address

12. Current Address*

14. City*

15. State*

16. Zip Code*

18. Phone Number*

22. Property Address*

24. City*

25. State*

26. Zip Code*

28. Township of:*
    -- Select One --ArcadeAtticaBenningtonCastileCovingtonEagleGainesvilleGenesee FallsJavaMiddleburyOrangevillePerryPikeSheldonWarsawWethersfield

29. Number of Water Wells Located on Property

30. 
    Lot Size (In Acres)

32. Number of Bedrooms*
    -- Select One --234567

33. 
    Garbage Grinder

    1. Yes
    2. No

34. Large Spa Tub That is Drained After Use

    1. Yes
    2. No

36. Person or Firm Constructing System

38. Nearest Crossroads / Directions to Property

42. Total Amount Mailed ($)

    Note * Payment may be made online by clicking the link or form must be printed and mailed to our office with appropriate fee

43. Payments

    Make check payable to the Wyoming County Health Department:<br>5362 Mungers Mill Road<br>Silver Springs, NY 14550<br>**Appointments may not be made until payment is recieved by this office.

    Make check payable to the Wyoming County Health Department:
    5362 Mungers Mill Road
    Silver Springs, NY 14550
    **Appointments may not be made until payment is recieved by this office.

44. Pay Now

    Click Here to Pay Online with Gov Pay

    Please pay amount associated with Reason for Permit field that was selected

46. E-Signature: The Wyoming County Health Department is hereby authorized to inspect the above named property to evaluate the water supply and the sewage disposal system. By electronically signing this form you agree to this authorization.*

    Property Owner Signature

47. 
    
    Date*
    
    
    Date

Leave This Blank:


48. 1. Receive an email copy of this form.
49. Email address

    This field is not part of the form submission.

50. Submit Submit and Print

* indicates a required field