Form Center

2. 
3. Wyoming County Health Department
   Environmental Division
   5362 Mungers Mill Road, Silver Springs, NY 14550
   Telephone 585-786-8894
   Application for Simulated Occupancy for Property Transfers
5. This procedure is not required, but may be used if desired for homes that are vacant and unoccupied less than 90 days. An occupied home is a home where people reside, sleep, shower, wash and cook on a full time basis. For the purposes of this test, use of the house that involves only daytime use such as washing and cleaning or perfoming construction or other work on a house is not considered occupying the house.
7. The following conditions must be met for this application to be considered:
   1. Record of construction of the wastewater disposal system is on file at the Wyoming County Health Department with all system components less than 40 years old
   2. Buyer and seller (or their Attorneys, or Powers of Attorney) submit this form requesting a simulated occupancy dye test along with an Application for Sewage and/or Water System Inspection.
   3. House vacant less than 90 days prior to the test.
   4. The outlet cover of the septic tank uncovered for observation - Available for us to remove before, during, and after water is run.
   5. The septic tank shall be full prior to the initial appointment date with the Health Department. In addition, all procedures must be completed in accordance with Schedule A: Documented Water use form.
   6. Please be aware that even if this procedure is followed and water is run into the system as described, the Health Department reserves the right to require a dye test 30 days after occupancy if any unsatisfactory conditions are found during or after the dye test, including but not limited to:
   ---- A. Water level in septic tank indicates system may not be functioning properly.
   -----B. Water not run as per instructions
   -----C. Proximity of surface water or drainage issues near the septic system
   -----D. Excessive or lush vegetation in the area of the septic system.
9. Property Information
11. Seller Name*
12. Buyer Name*
14. Street Address*
16. Township*
    -- Select One --ArcadeAtticaBenningtonCastileCovingtonEagleGainesvilleGenesee FallsJavaMiddleburyOrangevillePerryPikeSheldonWarsawWethersfield
18. Indicate person who will be running the water during the period of simulated occupancy:
20. Name*
21. Address*
23. Relationship to Seller / Employer or Company Name*
24. Phone Number*
26. Certification*

    1. By checking this box, I attest to the fact that I am the Seller / Seller's Attorney / POA for the Seller, and that I conscent to the Simulated Occupancy Procedure as listed above
    2. By checking this box, I attest to the fact that I am the Buyer / Buyer's Attorney / POA for the Buyer, and that I conscent to the Simulated Occupancy Procedure as listed above
28. Name of Seller / Seller's Attorney / POA For Seller
29. Phone Number
31. Name of Buyer / Buyer's Attorney / POA for Buyer
32. Phone Number
Leave This Blank:


34. 1. Receive an email copy of this form.
35. Email address

    This field is not part of the form submission.

36. Submit

* indicates a required field