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2. 
3. Wyoming County Health Department
   Environmental Division
   5362 Mungers Mill Road, Silver Springs, NY 14550
   Telephone 585-786-8894
   Sewage Disposal System Permit Waiver
5. Note
   This office recommends that prior to any development of vacant land a comprehensive site plan be established as to the placement of buildings and infrastructures including the well and wastewater disposal systems serving the property. With this being noted this office also recognizes that not all properties that are developed need potable water and wastewater disposal systems to serve them. As a result the requirement to submit an Application for Sewage Disposal Permit and subsequent percolation test may be waived by completing the following
7. Owner / Applicant Name*
8. Email Address
10. Current Address*
12. City*
13. State*
14. Zip Code*
16. Phone Number*
20. Property Owner Name
21. Property Tax ID #
23. I hereby request that the Application for Sewage Disposal Permit be waived for the following property noting that there will be no potable water serving the proposed construction.
25. Property Address*
27. City*
28. State*
29. Zip Code*
31. Township of:*
    -- Select One --ArcadeAtticaBenningtonCastileCovingtonEagleGainesvilleGenesee FallsJavaMiddleburyOrangevillePerryPikeSheldonWarsawWethersfield
32. Number of Water Wells Located on Property
33. 
    Lot Size (In Acres)
35. Nearest Crossroads / Directions to Property
37. Proposed Construction
41. E-Signature: I certify that the above information is accurate and agree to assume all responsibility for the installation of a wastewater disposal system if and when potable water (Well, Spring, etc.) is supplied to the property to serve the proposed development. I understand that this may result in the hiring of a professional engineer to design the system assuring that it is in full compliance with New York State and Wyoming County Sanitary Code regulations. I further understand that any violation of the New York State and Wyoming County Sanitary Code may result in an enforcement hearing and/or the issuance of fines.*
    Property Owner Signature
42. 
    
    
    
    
    
    Date*
    
    
    
    
    
    
    Date
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44. 1. Receive an email copy of this form.
45. Email address

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