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2. 
3. Wyoming County Health Department
   Environmental Division
   5362 Mungers Mill Road, Silver Springs, NY 14550
   Telephone 585-786-8894
   Non-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. Applicant / Buisness Name*
10. Email Address
12. Mailing Address*
14. City*
15. State*
16. Zip Code*
18. Phone Number*
19. Contact Person & Title
21. Type of Buisness*

    1. Agricultural

    1. Commercial

    1. Municipal

    1. Other
23. Other Buisness Type
27. Property Address*
29. City*
30. State*
31. Zip Code*
33. Township of:*
    -- Select One --ArcadeAtticaBenningtonCastileCovingtonEagleGainesvilleGenesee FallsJavaMiddleburyOrangevillePerryPikeSheldonWarsawWethersfield
34. Lot Size (In Acres)
36. Source of Water*

    1. Public
    2. Well
    3. Spring
    4. Other
37. Other Source of Water
39. Water Usage in Gallons Per Day
40. Current # of Employees
41. Future # of Employees
43. Food Service Kitchen

    1. Yes
    2. No
44. Public Usage of Facility*

    1. Yes
    2. NO
45. Average Daily # of People
47. Reason for Permit
49. Person or Firm Constructing System
51. Nearest Crossroads / Directions to Property
55. 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
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.
57. Pay Now
    Click Here to Pay Online with Gov Pay

    Please pay amount associated with Reason for Permit field that was selected
59. 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
60. 
    
    Date*
    
    
    Date
Leave This Blank:


62. 1. Receive an email copy of this form.
63. Email address

    This field is not part of the form submission.

64. Submit Submit and Print

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