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3/23/2026 Cayuga County Health Department 8 Dill Street Auburn, NY 13021 (315) 253-1405 PROPERTY INFORMATION/OWNER INTERVIEW 1. Owner: Tax Map 2. Property 911 Town: 3. Owner’s Mailing 4. Telephone: E-Mail: 5. Property Use: Residential Commercial: Type Other 6. Is the property currently occupied (15 or more consecutive days)? yes no Is the property used seasonally? yes no 7. Number of bedrooms (total # for multiple homes connected to one 8. Garbage Disposal? yes no Washing Machine? yes no Water Softener? yes no; Does backwash discharge to septic system? yes no 9. Septic Tank Holding tank Date of last tank pump-out? by If a holding tank, how often is it pumped (as needed is not acceptable) High-level Alarm? yes no 10. Have modifications been made to the septic system since the last inspection? yes no If yes, 11. Has the septic system had any problems? (slow draining plumbing, odors, back-ups, etc.) yes no If yes, 12. What is the water supply? Public Drilled Well Dug Well Lake Is there enough water to complete the inspection? yes no OWNER VERIFICATION OF INFORMATION 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 New York State punishable as a Class A Misdemeanor (PL Sec. 210.45). I certify that to the best of my knowledge the information I have provided herein is correct. Signature of (must be an adult) Print Name of Agent’s Title Cayuga County Health Department Wastewater Treatment System Inspection Form Pass: Yes___ No___ Inspection Type Routine Property Transfer Date of inspection: ---PAGE BREAK--- 3/23/2026 Cayuga County Health Department 8 Dill Street Auburn, NY 13021 (315) 253-1405 SITE INSPECTION/DYE TESTING 13. Was plumbing inspected to verify wastewater discharge? yes no; if no, explain in the comments section. Is there a basement floor drain? yes no 14. Does all wastewater discharge to only one septic system? yes no; if no, explain in the comments section. 15. Evidence of system problems: Odors yes no Lush/changes in vegetation yes no Saturated soils yes no Recent/past failure yes no 16. Are drainage pipes or catch basins observed? yes no Inspected for dye and/or wastewater discharge? yes no N/A (Location of drainage pipes/catch basins must be shown on the sketch) 17. Stormwater ponding observed? yes no; if yes, describe location 18. Distance of absorption area to nearest water well -including those on adjacent property (in ft.) 19. Distance of absorption area to nearest watercourse (lake, creek, pond, wetlands) (in ft.) 20. If the system has a pump, does it appear to operate properly? yes no N/A Equipped with alarm? yes no 21a. Which fixtures were turned on: 21b. Where was the dye introduced: a. toilet yes no a. toilet yes no b. bathtub/shower yes no b. bathtub/shower yes no c. bathroom sink yes no c. bathroom sink yes no d. kitchen sink yes no d. kitchen sink yes no e. washing machine/utility sink yes no e. utility sink yes no f. f. 22. Volume of water entered into system Calculate flow rate (gallons per minute). a. Routine Inspection: 20 gallons per bedroom; 100 gallons maximum Flow start stop total total volume________gals b. Property Transfer Inspection (dwelling occupied for at least 15 consecutive days prior to test): 55 gallons per bedroom; 110 gallons minimum Flow start stop total total volume________gals c. Property Transfer Inspection (dwelling unoccupied): 110 gallons per bedroom; 220 gallons minimum Flow start time______ stop total total volume________gals 23. Evidence of dye or wastewater discharge: yes no Describe 24. Date of re-visit (if (You must re-visit if a holding tank) 25. Evidence of dye or wastewater discharge upon re-visit: yes no Describe 26. Does the system pass inspection? yes no ---PAGE BREAK--- 3/23/2026 Cayuga County Health Department 8 Dill Street Auburn, NY 13021 (315) 253-1405 General Comments/Problems/Additional Information: Inspector’s Verification of Inspection 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 New York State punishable as a Class A Misdemeanor (PL Sec. 210.45). CERTIFICATION STATEMENT I certify that I have personally inspected the wastewater treatment system at this address and that the information reported is true and complete as of the time of inspection. I also certify that the ground was not frozen and that there was no snow cover on this property or adjacent properties at the time the inspection was conducted. The inspection was based on my training and experience in the proper function and maintenance of wastewater treatment systems. Inspector (please sign) Inspector (please print) Disclaimer of Assessment: Neither the inspector nor Cayuga County warranty operation of the wastewater treatment system described in this inspection report. This report must be submitted to the Cayuga County Health Department within 30 business days of the inspection (seven business days if inspection failed). The inspector is required to notify the Cayuga County Health Department of a failed system within one business day of the inspection. For quality control purposes the Cayuga County Health Department may visit the site for verification of statements. ---PAGE BREAK--- 3/23/2026 Cayuga County Health Department 8 Dill Street Auburn, NY 13021 (315) 253-1405 Owner: Indicate Direction 911 Date of Inspection