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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
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.
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.
   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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