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Schedule A: Documented Water Use Form

2. 

3. Wyoming County Health Department
   Environmental Division
   5362 Mungers Mill Road, Silver Springs, NY 14550
   Telephone 585-786-8894
   Schedule A: Documented Water Use Form

   Schedule A: Documented Water Use Form

5. Definition: The following Procedure is not required but can be done by request in advance, for eligible properties that are vacant on the day of inspection. This may avoid dying after occupancy.
   **The Wyoming County Health Department must receive the completed "Application for Simulated Occupancy for Property Transfers" form before the appointment will be scheduled.

   **The Wyoming County Health Department must receive the completed "Application for Simulated Occupancy for Property Transfers" form before the appointment will be scheduled.

7. Procedure:
   1. Water must be introduced into the septic system at a rate of 110 gallons per bedroom (i.e. 2 bedroom home - 220 gallons, 3 bedroom home - 330 gallons, etc.) each day for seven days after the dye is placed in the system.<br>2. Document water usage on this form by either timing water flow, meter reading usage or bulk tank discharge. Time of day water is run must be recorded on chart below<br>3. This water must be discharged into the septic system (Septic Tank). Since some wells are sensitive to continuous flow the daily amount may have to be done by running water for short periods of time throughout the day. This office cautions that placing large volumes of water into the system over verry short time periods may be detrimental to the system.<br>4. Submitt the documented water usage form.<br><br>*Inspector may require further inspection, excavation, or re-dying of the septic system in order to state that the system appears to be functioning satisfactorily.

   1. Water must be introduced into the septic system at a rate of 110 gallons per bedroom (i.e. 2 bedroom home - 220 gallons, 3 bedroom home - 330 gallons, etc.) each day for seven days after the dye is placed in the system.
   2. Document water usage on this form by either timing water flow, meter reading usage or bulk tank discharge. Time of day water is run must be recorded on chart below
   3. This water must be discharged into the septic system (Septic Tank). Since some wells are sensitive to continuous flow the daily amount may have to be done by running water for short periods of time throughout the day. This office cautions that placing large volumes of water into the system over verry short time periods may be detrimental to the system.
   4. Submitt the documented water usage form.
   
   *Inspector may require further inspection, excavation, or re-dying of the septic system in order to state that the system appears to be functioning satisfactorily.

9. Method of Water Discharge

   1. Bulk Tank Discharge Method
   2. Water Meter Reading Method
   3. Timed Flow Method

   One method for determining flow for Timed Flow Method: Turn on faucet(s) to desired level, then record the time it takes to fill up a gallon container. Gal per Min = 60 / (number of seconds it takes to fill a one gallon container)

11. Date

12. Time Start

13. Time Finish

14. Gallons Dispensed

16. Date

17. Time Start

18. Time Finish

19. Gallons Dispensed

21. Date

22. Time Start

23. Time Finish

24. Gallons Dispensed

26. Date

27. Time Start

28. Time Finish

29. Gallons Dispensed

31. Date

32. Time Start

33. Time Finish

34. Gallons Dispensed

36. Date

37. Time Start

38. Time Finish

39. Gallons Dispensed

41. Date

42. Time Start

43. Time Finish

44. Gallons Dispensed

46. Total Gallons

48. I verify the above water flow into sewage disposal system was accomplished by myself and/or representative on the property located at:

50. In the Town of:
    -- Select One --ArcadeAtticaBenningtonCastileCovingtonEagleGainesvilleGenesee FallsJavaMiddleburyOrangevillePerryPikeSheldonWarsawWethersfield

52. Name

53. Date
    Date

    Date

55. Relationship to property owner / Employer or Company Name

57. Date

58. Time Start

59. Time Finish

61. Meter Start

62. Meter Finish

63. Gallons

65. Date

66. Time Start

67. Time Finish

69. Meter Start

70. Meter Finish

71. Gallons

73. Date

74. Time Start

75. Time Finish

77. Meter Start

78. Meter Finish

79. Gallons

81. Date

82. Time Start

83. Time Finish

85. Meter Start

86. Meter Finish

87. Gallons

89. Date

90. Time Start

91. Time Finish

93. Meter Start

94. Meter Finish

95. Gallons

97. Date

98. Time Start

99. Time Finish

101. Meter Start

102. Meter Finish

103. Gallons

105. Date

106. Time Start

107. Time Finish

109. Meter Start

110. Meter Finish

111. Gallons

113. Total Gallons

115. I verify the above water flow into sewage disposal system was accomplished by myself and/or representative on the property located at:

117. In the Town of:
     -- Select One --ArcadeAtticaBenningtonCastileCovingtonEagleGainesvilleGenesee FallsJavaMiddleburyOrangevillePerryPikeSheldonWarsawWethersfield

119. Name

120. Date
     Date

     Date

122. Relationship to property owner / Employer or Company Name

124. Date

125. Time Start

126. Time Finish

128. Flow Rate Gal. Per Min.

129. Minutes Run

130. Gallons

132. Date

133. Time Start

134. Time Finish

136. Flow Rate Gal. Per Min.

137. Minutes Run

138. Gallons

140. Date

141. Time Start

142. Time Finish

144. Flow Rate Gal. Per. Min

145. Minutes Run

146. Gallons

148. Date

149. Time Start

150. Time Finish

152. Flow Rate Gal. Per Min.

153. Minutes Run

154. Gallons

156. Date

157. Time Start

158. Time Finish

160. Flow Rate Gal. Per Min.

161. Minutes Run

162. Gallons

164. Date

165. Time Start

166. Time Finish

168. Flow Rate Gal. Per Min.

169. Minutes Run

170. Gallons

172. Date

173. Time Start

174. Time Finish

176. Flow Rate Gal. Per Min.

177. Minutes Run

178. Gallons

180. Date

181. Time Start

182. Time Finish

184. Flow Rate Gal. Per Min.

185. Minutes Run

186. Gallons

188. Date

189. Time Start

190. Time Finish

192. Flow Rate Gal. Per Min.

193. Minutes Run

194. Gallons

196. Date

197. Time Start

198. Time Finish

200. Flow Rate Gal. Per Min

201. Minutes Run

202. Gallons

204. Date

205. Time Start

206. Time Finish

208. Flow Rate Gal. Per Min.

209. Minutes Run

210. Gallons

212. Date

213. Time Start

214. Time Finish

216. Flow Rate Gal. Per Min.

217. Minutes Run

218. Gallons

220. Date

221. Time Start

222. Time Finish

224. Flow Rate Gal. Per Min.

225. Minutes Run

226. Gallons

228. Date

229. Time Start

230. Time Finish

232. Flow Rate Gal. Per Min.

233. Minutes Run

234. Gallons

236. Total Gallons

238. I verify the above water flow into sewage disposal system was accomplished by myself and/or representative on the property located at:

240. In the Town of:
     -- Select One --ArcadeAtticaBenningtonCastileCovingtonEagleGainesvilleGenesee FallsJavaMiddleburyOrangevillePerryPikeSheldonWarsawWethersfield

242. Name

243. Date
     Date

     Date

245. Relationship to property owner / Employer or Company Name

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247. 1. Receive an email copy of this form.
248. Email address

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249. Submit

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