Ontario County Uniform Procedures Program


System Inspection Request Form
Individual Residential Wastewater Treatment System
 

To: _________________________________________________                       Date: _______/_______/_______
                                (Name of Applicant)
From: Tad Gerace - Conservation District Technician

Re: Onsite Wastewater System Inspection Information Request for:

_____________________________________________________

_____________________________________________________
                                  (Site Address)

You have requested that Ontario County SWCD inspect the onsite wastewater treatment system serving the above-referenced property. In order for an inspector to do the best possible job, it would be helpful to have some basic knowledge about the site prior to scheduling the inspection. We need information about the property, the treatment system, and the current or most recent occupants, and would also like to confirm access to the property and dwelling, and that the pre-inspection preparation will be done.

Attached you will find a System Inspection Information Request form, which must be completed, signed, and returned to this office prior to scheduling the inspection. Please provide information on the location of any underground utilities and/or structures on the property. It can be dangerous to both inspectors and utilities if proper information is not provided prior to the inspection.

Following the actual inspection, you will receive a System Inspection Findings Report, detailing the results of the inspection. Both the form and the worksheet are standardized, used by those who have completed specialized training and are registered by the New York Onsite Wastewater Treatment Training Network (OTN) as certified inspectors. The inspection may include a dye test, and if so, we may have to revisit the property at a later time.

The fee for this service is $175.00 and must be paid prior to the release of the completed report. An additional fee may be required if the inspector must hand dig to expose system components. If you have questions or rather fax the completed form, appropriate numbers are listed above.

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

Tad Gerace, Conservation District Technician
480 North Main Street
Canandaigua, NY 14424

Tel: (585) 396-1450 Ext. 21
Fax: (585) 396-0137
 

 
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 if possible)
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 __________________________________ *Payment is due before report is released
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 the onsite wastewater treatment system(s), including all system components 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:
  Tad Gerace, Conservation District Technician Tel: (585) 396-1450 Ext. 21
  480 North Main Street Fax: (585) 396-0137
  Canandaigua, NY 14424