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On-Site Wastewater Disposal System Specific Waiver

2. 

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

   On-Site Wastewater Disposal System Specific Waiver Request

   On-Site Wastewater Disposal System Specific Waiver Request

5. General Information

7. Name of Applicant:

8. Email Address

10. Address

12. City

13. State

14. Zip Code

16. Site Address If Different from Above

18. City

19. State

20. Zip Code

22. Name of Design Professional or Registered Installer:

24. Address

26. City

27. State

28. Zip Code

30. Describe area(s) of deviation from Appendix 75-A (NYS Sanitary Code):

    1. Separation distance cannot be achieved
    2. Excessive slope
    3. High seasonal groundwater
    4. Soil unsuitable
    5. Inadequate area available
    6. Other

32. If Other, please explain

34. Proposed Wastewater Treatment System Design or System Improvements:

36. Will the deviation(s) noted affect the operation of the operation of the wastewater treatment system?

    1. Yes
    2. No

38. If Yes, please describe

    1. Risk of well, spring or water service contamination
    2. Risk of surface water contamination
    3. Risk of inadequately treated sewage on the ground surface
    4. Operation of sewage system is subject to mechanical problems
    5. Other

40. If Other, please explain

Leave This Blank:


41. 1. Receive an email copy of this form.
42. Email address

    This field is not part of the form submission.

43. Submit

* indicates a required field