1. GENERAL INFORMATION

2. Owner:______________________________________________________________________________________________________

3. Property exact location:_________________________________________________________________________________________

4. Owner’s 911 Mailing Address:________________________________________________________ Zip Code:________________

5. Telephone: Home:___________________________ Work:____________________________ Property:___________________

6. Prior Owner: _________________________________________________________________________________________________

7. Select one that best describes location of sewage disposal system:

[] Borders MHWM of Owasco Lake or Little Sodus Bay.

[] Does not border Lake or Bay but is within 500 ft. of MHWH of Lake or Bay.

[] System located in Owasco Lake or Little Sodus Bay Watershed.

[] None of the above mentioned.

8. Property Use: [] Residence [] Multiple Residence [] Vacant [] Commercial: Type______________________________________

[] Other - describe:_____________________________________________________________

9. Does the Health Department have a construction or modification plan of the system on record? [] yes [] no

10. SPEDES permit? [] yes [] no Date SPEDES permit expires________________

2. System Information (Mark All That Apply)

11. Type of Wastewater System:

[] Septic Tank with Absorption Trenches [] Septic Tank with Absorption Bed [] Septic Tank with Seepage Pit (dry well)

[] Septic Tank with Sand Filter (effluent discharge to surface [] yes [] no) [] Aerobic Septic Tank with Absorption Field

[] Seepage Pit (dry well) without Septic Tank) [] Holding Tank [] Privy [] Commercial System [] Unknown

12. Septic/Holding tank size______________(gallons) Date last pumped______________ By whom___________________________

13. Absorption Field:

Number of laterals________________ Length of each lateral____________________

Total lateral length________________ Overall bed dimensions______________

14. Dry Wells/Seepage pits: Number_______________________ Size of each_____________________

15. Pump [] yes [] no; Dosing siphon [] yes [] no

Is pump or dosing siphon equipped with an alarm? [] yes [] no

Storage Capacity per pump cycle_________ (gallons)

2. OWNER INTERVIEW

16. Date of system construction:____________________________ Year house was built:____________________________

17. Date of any modifications to system_____________________________________

18. Is the property used seasonally? [] yes [] no

19. Is the property currently occupied? [] yes [] no

20. How long has the property been currently occupied?________________________(days/months/years)

21. Describe periods of maximum occupancy:_________________________________

22. Average number of persons using the property_________________________

23. Number of:

a. Bedrooms (total # for multiple homes)_______ Bathrooms_______ Hot Tubs________

b. Toilets________ Type: [] Old Standard [] New Standard [] Water Saving [] Other

c. Sinks________ Faucet Type: [] Old Standard [] Water Saving [] Other

d. Showers/Tubs_____ Faucet Type: [] Old Standard [] Water Saving [] Other

e. Dishwashers_______ Garbage Disposal_______ Washing Machines_______

f Water Softener/Treatment Equipment [] yes [] no Backwash Discharges into Septic System [] yes [] no

24. Has the septic system had any problems?

a. Odors [] yes [] no

b. Slow draining plumbing [] yes [] no

c. Backing up of sewage into house [] yes [] no

d . Surfacing of sewage [] yes [] no

e. Other, such as seasonal [] yes [] no

f. Describe any problems:___________________________________________________________________________________

25. If system has an Aerobic Tank, when was tank last serviced __________(date) _______________(by whom) [] not applicable

26. Is holding tank equipped with alarm or other device to detect leakage or overflow? [] yes [] no [] not applicable

27. Does homeowner maintain log of holding tank or septic tank pump-out? [] yes [] no

28. Was log of holding tank or septic tank pump outs reviewed by inspector? [] yes [] no [] not applicable

29. If system has holding tank, what is frequency of pumping (eg. weekly, monthly, etc.)?______________ [] not applicable

30. Are there any separate disposal systems (seepage pits/drywells) for the kitchen, second bath, laundry, etc.? [] yes [] no;

If yes, describe these drains and their location:

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

31. Are there any drainage pipes or storm drains on the property? [] yes [] no; Are they private? [] yes [] no

32. What is your water supply; [] Public [] Lake [] Well [] Creek [] Other____________________

Is the quantity of flow adequate? [] yes [] no

2. Owner Verification of Interview

Notice: In a written statement filed with the County, any person who knowingly makes a false statement which such person does not believe to be true has committed a crime under the laws of the State of New York punishable as a Class A Misdemeanor (PL Sec. 210.45).

I certify that to the best of my knowledge the information I have provided in this interview is correct.

Signature of Owner/Agent:____________________________________________________ Date:___________________

(must be an adult)

Agents title_______________________________________________________

3. SITE INSPECTION

1. Date and Review of System Plans

33. Date of Inspection:_________________________________ (If a three day test, enter all dates)

34. Did Inspector review construction or modification plans of system on file with the Health Department? [] yes [] no

2. Interior Plumbing

35. Does all wastewater discharge to the septic system? [] yes [] no

3. Sewage Disposal System

Provide comments and system/site sketch as described in the procedures guide. Use the designated "SYSTEM/SITE COMMENT AND SKETCH SHEET" attached to this form.

4. General Information (enter the following information based on the inspection)

36. Evidence of system problems:

a. Odors [] yes [] no

b. Saturated soils [] yes [] no

c. Lush vegetation [] yes [] no

d. Changes in vegetation [] yes [] no

e. Other [] yes [] no

Describe:________________________________________________________________________________________________

37. Were all drainage pipes inspected for dye? [] yes [] no [] N/A

38. Evidence of wastewater discharge to water course or ground surface: [] yes [] no

Describe:________________________________________________________________________________________________

39. Evidence of storm water ponding on system: [] yes [] no

Describe:________________________________________________________________________________________________

40. Evidence of storm water discharge to system: [] yes [] no

Describe:________________________________________________________________________________________________

41. Evidence of rock outcroppings: [] yes [] no

Describe:________________________________________________________________________________________________

42. Shortest distance from absorption area to (in feet):

a. Lake or Bay (MHWM), stream, spring, pond, etc._________________

b. Nearest Property Line__________________

c. Nearest Well-including those on adjacent property________________

d. Nearest Dwelling________________

e. Elevation of Lake or Bay (i.e. Owasco Lake, Little Sodus Bay, Cross Lake, etc.) at the day of inspection_________(feet)

f. Other pertinent features__________________________________________________________________________________

43. If the system has a pump: [] not applicable

a. Does the pump appear to operate properly? [] yes [] no

b. Does the pump basin have any visible overflows? [] yes [] no

5. Dye Testing (inform owner regarding the quantity of water to be used)

44. Which fixtures were turned on:

a. toilet [] yes [] no

b. bathtub/shower [] yes [] no

c. bathroom sink [] yes [] no

d. kitchen sink [] yes [] no

e. washing machine/utility sink [] yes [] no

45. Where was the dye introduced:

a. toilet [] yes [] no

b. bathtub/shower [] yes [] no

c. bathroom sink [] yes [] no

d. kitchen sink [] yes [] no

e. washing machine/utility sink [] yes [] no

46. Volume of water entered into system (Calculations)

Calculate flow rate (e.g. gallons per minute), the time dye introduced and the fixtures turned on, and the time fixtures turned off.

a. Routine Inspection: 20 gal/bedroom

flow rate_________ start time_______ stop time_______ total time_______ total volume________(gals)

b. Property Transfer or Refinance Inspection (dwelling occupied for at least 15 consecutive days prior to test):

75 gal/bedroom; 150 gallons Minimum; (Requires Septic Tank Pump-Out Report)

flow rate_________ start time_______ stop time_______ total time_______ total volume________(gals)

c. Property Transfer or Refinance Inspection (dwelling unoccupied):

150 gal/bedroom x 3 days; (Requires Septic Tank Pump-Out Report)

Day 1: flow rate__________ start time______ stop time_______ total time_______ volume________(gals)

Day 2: flow rate__________ start time______ stop time_______ total time_______ volume________(gals)

Day 3: flow rate__________ start time______ stop time_______ total time_______ volume________(gals)

total volume________(gals)

47. Evidence of dye: [] yes [] no Describe location:___________________________________________________________________

48. Date of re-visit:_______________ (remember you must re-visit if a holding tank)

49. Evidence of dye: [] yes [] no Describe location:___________________________________________________________________

50. Does system pass inspection? [] yes [] no

6. Drainage Pipe Discharge Testing [] not applicable

For properties bordering the mean high water mark of Owasco Lake or Little Sodus Bay ONLY Note: Use additional sheets if more than one drainage pipe.

51. Describe location, diameter, length of private drainage pipe(s) sampled:________________________________________________

______________________________________________________________________________________(also indicate on sketch)

52. Name of laboratory testing sample:_______________________________________________________________________________

53. Results of fecal coliform test:____________________________________________________________________________________

Date and time of sampling:_____________________________(attach Chain of Custody and Report from Lab)

54. Results of second fecal coliform test(s):___________________________________________________________________________

Date and time of sampling: _____________________________(attach Chain of Custody and Report from Lab)

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2. Differences Between Information From Owner Interview, Health Department Records, And From Site Inspection.

Findings_____________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

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________________________________________________________________________________________________________________

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3. Inspector’s Verification of Inspection

I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, and accurate and completed as of the time of inspection. The inspection was based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.

Signature:______________________________________________________ Date:__________________________

(please sign)

Inspector:______________________________________________________ Certification No:____________________

(please print)