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CAYUGA COUNTY HEALTH DEPARTMENT - ENVIRONMENTAL DIVISION 8 Dill Street Auburn, NY 13021 Phone (315) 253-1405 Fax (315) 253-1478 Septic System Variance Request Form Date: _ Cayuga County Tax Map Number: _ Town: 911 Address of Property: _ Does the property border Owasco Lake or Little Sodus Bay? Yes No I request that the Health Department (Please check all that apply) Waive a Property Transfer Inspection Extend a Property Transfer Inspection until ______Waive a Routine Inspection Extend a Routine Inspection until ______Waive a Septic Tank Pump Out Extend a Septic Tank Pump Out until As required under the Cayuga County Sanitary Code for the following reasons: This variance request will be addressed by the Variance Committee for the Cayuga County Board of Health. For Property Transfer Inspection: For Routine Inspection: Buyer Name and Address Owner Name and Address Phone # ( ) _ Phone # ( ) _ Signature Signature Seller Name and Address Phone # ( ) _ Signature Please Note: All requests must be filled out completely and signed in order to be processed. All incomplete requests will be returned. SIGN SIGN SIGN