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2. 
3. Wyoming County Health Department
   Environmental Division
   5362 Mungers Mill Road, Silver Springs, NY 14550
   Telephone 585-786-8894
   Sewage and/or Water System Inspection
5. Reason for Inspection*

   1. Property Transfer

   1. Refinance

   1. Illness

   1. Other Reason
7. Other Reason
9. Inspection of Premises at (Street Address)*
11. City
12. Township of:*
    -- Select One --ArcadeAtticaBenningtonCastileCovingtonEagleGainesvilleGenesee FallsJavaMiddleburyOrangevillePerryPikeSheldonWarsawWethersfield
14. Has the home been lived in for the past 30 days?*

    1. Yes
    2. No
15. How long since the home has been lived in?*
17. Is the home lived in seasonally?

    1. Yes
    2. No
21. Owner / Seller Name
22. Phone Number
24. Contact Name for Scheduling Appointment
25. Phone Number
27. Current Occupant Name (If different than the seller)
28. Phone Number
30. Buyer Name
31. Phone Number
35. Send Results to (Name)*
36. Send Results Via*

    1. Mail
    2. Email
    3. Fax
38. Fax Number*
39. Email Address*
41. Address*
43. City*
44. State*
45. Zip Code*
49. Note
    Please be aware the final report is valid for 90 days. Schedule your appointment accordingly to avoid a re-inspection.
51. The following inspections are requested:*

    1. Septic system and water (fee is $250)
    2. Septic system dye only (fee is $200)
    3. Septic System re-dye only (fee is $100)
    4. Water only - coliform bacteria (fee is $75)
    5. Re-Sample - coliform bacteria (fee is $50)
53. Note
    Additional tests may be required, Please check with your financial institution. Additional tests are $15 each (when performed with above service).
55. Please check the desired tests:

    1. Lead
    2. Nitrate
    3. Nitrite
56. Payments
    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.
58. 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
59. Pay Now
    Click Here to Pay Online with Gov Pay

    Please total all testing being requested to submit payment online
61. E-Signature: The Wyoming County Health Department is hereby authorized to enter the above named premises to inspect and evaluate the water supply and/or the sewage disposal system. By electronically signing this form you agree to this authorization.*
    Authorized Signature of one of the following - owner, owner's attorney, or executor of estate
62. 
    
    Date*
    
    
    Date
Leave This Blank:


64. 1. Receive an email copy of this form.
65. Email address

    This field is not part of the form submission.

66. Submit Submit and Print

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