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On-Site Wastewater Disposal System Specific Waiver

  1. County Seal (color)

  2. 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

  3. General Information

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

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

  6. If Yes, please describe

  7. Leave This Blank:

  8. This field is not part of the form submission.