Canandaigua Lake
Watershed Commission

                v City of Canandaigua
                v Village of Rushville
                v Village of Palmyra
                v Village of Newark
                v Town of Gorham
Onsite Wastewater System Inspection Request
 

To: _________________________________________________                       Date: _______/_______/_______
                                (Name of Applicant)
From: George V. Barden, Canandaigua Lake Watershed Inspector

Re: Onsite Wastewater System Inspection Information Request for:

_____________________________________________________

_____________________________________________________
                                  (Site Address)

To properly perform a system inspection, considerable information is needed about the property, the system and the current or most recent occupants. Access to the property and dwellings must be provided at the time of inspection. Some pre-inspection preparation is required to expose the system components.

Enclosed is a System Inspection Information Request form which must be completed, signed and returned to this office prior to scheduling an inspection. Results of the inspection will be presented in a System Inspection Site Report. The Inspection Request and the Site Report are standardized forms used by this office and others who have successfully completed training specific to onsite wastewater treatment system inspection techniques. Training and registration is provided by the New York State Onsite Wastewater Treatment Training Network (OTN).

Public or private underground utilities or structures must be located and marked. Dig Safely New York (UFPO) can be contacted at 1-800-962-7962 to locate public utilities that may be present. It can be dangerous to both the inspector and the utility if these are unmarked or not properly located before the inspection.

The inspection may include a dye test. If so, we may revisit the property to look for dye. If you observe dye when the inspector is not present, please call us immediately.

Fee for the inspection and Site Report is $175. Additional fees may be required if the inspector must hand-dig to expose system components. Payment is due upon completion of the inspection. All fees must be paid prior to the release of the completed Site Report.

Return the completed System Inspection Information Request form to the following address or fax number:

George Barden, Canandaigua Lake Watershed Inspector
480 North Main Street
Canandaigua, NY 14424

Tel: (585) 396-9716
Fax: (585) 396-1305
 

 
OTN SYSTEM INSPECTION INFORMATION REQUEST
Individual Residential Wastewater Treatment System
Page 1 of 2
 
Property and Owner Identification (Please attach property survey or tax parcel map)
Property address
 _____________________________
Tax parcel ID#
 ____________________________
_____________________________    
Property owner
 _____________________________
Address
 _____________________________
Phone
 __________________
  _____________________________
Fax
 __________________
Inspection Request Information
Requested by
 _______________________________    
Address
 _______________________________
Phone
 __________________
_______________________________
Fax
 __________________
Affiliation
 _____________________________________________________
Requested date of inspection (give two or three) ________________________________________________
Purpose of Request:
 ____property transfer     _____agency request     _____malfunction
____other (please specify) _________________________________
Inspection fee to be paid by ________________________________________________
Household Information
______ Owner occupied    or _____ Rental
______ Full-time               or _____ Seasonal      If seasonal, # weeks per year: _______
Last known date of occupancy: __________         Number of occupants: _______
Age of home: _______ Total square footage: ___________ # bedrooms: _______ # bathrooms: ________
Water-saving fixtures? ________yes _____no
Home business or hobby? (e.g. daycare, photography, taxidermy) ____yes ____ no   Type:____________________
Regularly used medications (e.g. chemotherapy, dialysis)? ______yes ______no
Are any wells located on the property ?_____yes ____ no        How many? _________
Household fresh water source: ______public ______wells(s) ______springs(s)_____ lake intake _____ other

List all public or private buried utilities or structures on the property (gas, electric, phone, etc.).
_______________________________________________________________________________________________
Onsite Wastewater Treatment System(s)
How many systems are on the property? _____________              Are system plans available? ______yes ______no
Year system(s) installed:    tank __________ leach system ____________
Are all system components wholly within the property boundaries? ______yes ______no
Does the system serve multiple properties? ______yes ______no
       If yes, describe: _____________________________________________________________________________
Maintenance
Service agreement? ______yes ______no          If yes, vendor's name _____________________________________
Date of last inspection: ___________________________________________________________________________
Frequency of pumping: _______________________________   Date tank last pumped: _______________________

 
OTN SYSTEM INSPECTION INFORMATION REQUEST
Individual Residential Wastewater Treatment System
Page 2 of 2
 
List known repairs/replacements and dates:
Date Type of repair or replacement
______________________ _______________________________________________________________
______________________ _______________________________________________________________
______________________ _______________________________________________________________
______________________ _______________________________________________________________
Operation
  System problems? ______ yes   ______no
  Sewage odors? ______ yes   ______no
  Direct surface discharges(s)? ______ yes   ______no
  Back-up of toilets? ______ yes   ______no
  Back-up of other fixtures (e.g. slow drains)? ______ yes   ______no
  Seasonal ponding or breakout of leach field? ______ yes   ______no
Statement of Acceptance of Conditions:
I agree to:
w
 ensure that the septic tank(s), distribution box(es) and/or seepage pit(s) will be uncovered prior to the requested inspection time.
w
 have a septage hauler on site to pump the tank AFTER the inspector arrives. Tank MUST be pumped in the presence of the inspector.
w
 have an authorized representative present at the site to provide access for inspection of interior plumbing.
w
 allow the inspector to verify information provided above and to conduct an inspection of all components of the onsite wastewater treatment system(s) and interior and exterior plumbing.
Signature of property owner or authorized agent
  To the best of my knowledge, the information provided above is accurate. I agree to be responsible for inspection fee payment.
  Please print name: __________________________________________________
  Affiliation: ____ owner ____ agent ______________________________________
  Signature: _________________________________ Date: ___________________
Comments/Directions to property/etc. (optional)
___________________________________________________________________________
___________________________________________________________________________
   
 
Please fax or mail this completed form to:
  George V. Barden Tel: (585) 396-9716
  Canandaigua Lake Watershed Inspector Fax: (585) 396-1305
  480 North Main Street
  Canandaigua, NY 14424