Ontario County Uniform Procedures Program


Soil Investigation Request
 

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

Re: Soil Investigation (Deep Hole & Perc Test) Request for:

_____________________________________________________

_____________________________________________________
                                  (Site Address)

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

Attached you will find a Soil Investigation Information Request form, which must be completed, signed, and returned to this office prior to scheduling the soil investigation. Public or private underground utilities or structures must be located and marked. Dig Safely New York (UFPO) can be contacted at 1-811-962-7962 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.

Following the soil investigation, you will receive a Soil Investigation Findings Report, detailing the results. 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 soil investigation may require a revisit to the property to verify soil conditions.

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 in excess during the soil investigation. 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)
Property address
 _______________________________
Tax parcel ID#
 ____________________________
_______________________________    
Property owner
 _______________________________
Address
 _______________________________
Phone
 __________________
  _______________________________
Fax
 __________________
Soil Investigation Request Information
Requested by
 _______________________________    
Address
 _______________________________
Phone
 __________________
_______________________________
Fax
 __________________
Affiliation
 _____________________________________________________
Requested date of soil investigation (give two or three) ________________________________________________
Purpose of Request:
 ____new construction     _____agency request     _____repair
____other (please specify) _________________________________
Inspection fee to be paid by ________________________________________________
Household Information
______ Vacant Lot   ______ 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 all perc test holes will be dug and presoaked according to the attached soil test proceedures form, prior to the requested inspection time;
w
 have a contractor with a backhoe on site to dig hole in the presence of the inspector;
w
 have an accurate site plan for all the following: house (proposed), well(s), property lines, ponds, etc.;
w
 have an authorized representative present at the site to provide access to lot for soil investigation;
w
 allow the inspector to verify information provided above and to conduct a soil investigation of the indicated site.
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 investigation 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 Tel: (585) 396-1450 Ext. 21
  Ontario County Soil and Water Conservation District Fax: (585) 396-0137
  480 North Main Street
  Canandaigua, NY 14424