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

    This field is not part of the form submission.

44. Submit

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