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AFFIDAVIT STATE OF NEW YORK) ss,: COUNTY OF CAYUGA) BEING FIRST DULY SWORN, DEPOSES AND SAYS: 1. I have personal knowledge of all facts stated herein. 2. I make the affidavit under oath to the Variance Committee of the Cayuga County Board of Health in support of my application for a variance from the requirements of the Sanitary Code of Cayuga County. 3. I have requested a variance from the requirements of (cross out if not applicable) inspecting and pumping out of the septic system at my property in the Town of Tax Map # herein the “Property”. 4. The basis from my request is that the residence located on this property is unoccupied and will remain unoccupied until 5. The septic tank on the property was last pumped out on by A receipt for such pumping is attached. 6. I make the above statements to the Variance Committee under penalty of perjury and with the intention and full recognition that the Variance Committee will rely upon such statements in making its determination whether to grant the variance I have requested. 7. I understand and acknowledge that, as a condition of the variance for which I am applying, my discharge permit will be suspended and the septic system on the Property may not be lawfully used and will not be used until I have obtained the necessary septic system inspection and advised the Environmental Health Division of the Cayuga County Health Department that occupancy of the Property has been or will be resumed. 8. I hereby authorize representatives of the Cayuga County Health Department to investigate the accuracy and/or continuing validity of any or all of the above statements in any manner they deem appropriate, including by unannounced inspection visits to the Property and by interviewing residents occupying other property in the vicinity of the Property. Affiant On this day of before me personally came to me known and known to me to be the affiant in the foregoing Affidavit and __he declared to me under oath that __he had read and understood the same fully and that the statements therein made were his/her sworn statements for all purposes therein declared and __he thereupon duly executed this instrument in my presence. Notary Public