Grant Application Form

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Grant Application Form

NYSDEC Septic System Replacement Grant Program for Findley Lake and Chautauqua Lake

Complete this application form and submit it with the required documents, or assistance may be delayed.

A. APPLICANT/OWNER INFORMATION

1. Name

2. Phone Number

3. Mailing Address

4. Email Address

B. PROPERTY INFORMATION

1. Street Address of Septic System (if different from mailing address)

2. County

3. Town Tax Id# (section/block/lot)

4. Property Type

4a. If you checked Commercial, please specify the nature and size of the business

4b. If you checked Residential, please indicate whether the property is used as

5. Number of bedrooms at the property

6. Year septic system was installed

7. description of the septic system installed

C. PROJECT INFORMATION

1. Describe any problems with your existing system

1A. If system has a septic tank:

a. What is the approximate size in gallons?

b. When was the last time it was pumped? Month/Year

c. What was the volume pumped out in gallons?

d. Who was the pump contractor?

e. Has tank been pumped more than once?

If yes, how frequently?

1B. What is septic tank constructed of?

1C. Is an "As-Built" drawing of the construction of the septic system available?

If yes, obtain a copy of the drawing and attach it.

One file only.
100 MB limit.
Allowed types: gif, jpg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip.

2. Project Type

3. Total Estimated Project Cost

4. Name of Septic System Project Contractor

Address

Phone Number

Signed

By signing this applicaiton form, the undersigned states that all the information contained in this application is true and correct.

Date

Grant Application Form