PT-0065-2019 Property Transfer Sewage Disposal Information Form
Town of Queensbury
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.gueensbury.net I
Date: �! r
To: L- 0 , 4 Cji1/
(Name of Applicant)
Re: Onsite Wastewater Treatment System Inspection Information Request for:
(Site Address)
Thank you for requesting an inspection for the onsite wastewater treatment system located on the property
referenced above. We look forward to completing a thorough inspection for you. You can help us do the best
job possible by providing some advance information to us about the site. Prior to our inspection, we request
information regarding the property and the onsite wastewater treatment system (septic system) on that
property. We also would like to confirm property access and that pre-inspection system preparation will be
completed prior to our arrival.
Enclosed is a Septic System Inspection Information form, which must be completed, signed and returned to
this office prior to scheduling an inspection. Following completion of the inspection,you will be sent a System
Inspection Site Report. The System Inspection Information Request and the System Inspection Site Report are
standardized forms used by the Town of Queensbury.
Please note the Town of Queensbury's fee for this service is$250. Be advised that all fees for services must be
paid prior to the site inspection. If you have any questions, please call. You may FAX or email the completed
Septic System Inspection Information form back to us.
Phone: (518) 761-8256 Fax: (518) 745-4437 Email: kated@queensbury.net
Thank you. D M U
Sincerely, FEB 0 8 2019
JJ TOWN OF QUEENSBURY
Jd BUILDING&CODES
Dave Hatin
Director of Building and Code Enforcement
Town of Queensbury
Building&Code Enforcement January 2019
Office Use Only
Permit#:Town Of
'..W(4w.
742 Bay Road,Queensbury,NY 12804 Fee: ���
P:518-761-8206 or 518-761-8205 www.gueensbury.net
Invoice#: 1221
SEWAGE DISPOSAL SYSTEM INSPECTION INFORMATION
Individual Residential Wastewater Treatment System
Property and Owner Information: (Please attach property survey or tax parcel map)
Property address: 2-jq /7 L2
Tax map number: '3�'j,8—f f
Property owner: Nko *414
Mailing Address(c/s/z): 46 1vpx
l3 1 NGt7/✓!, d/Z S�
Cell#: I/�—7 (7" I /a Land Line#: !✓/� _
Email:
Household Information:
#Bedrooms -7— #Bathrooms__] #Kitchens
Onsite Wastewater Treatment System:
How many systems are on the property?
Year system(s)installed: Tank YVIA, Size of Se tic Tank /t->M
Type of Absorption System: (., //✓� J��✓ C7j' CB
Are all system components wholly within the property boundaries? Yes _No
Are system plans available? Yes - , o
Does the system(s) serve multiple properties? Yes -2<No
If yes,describe
Maintenance:
Service agreement? _Yes &No If yes,vendor name
Date of last inspection N/A Date tank last pumped N/A
Frequency of pumping /A
Building&Code Enforcement January 2019
List known repairs/replacements, with dates:
Date Type of Repair/Replacement
Operation: AV V LVX&/Z. �� r� m 7"r
System problems? Yes No
Sewage odors? Yes No
Direct surface discharge(s)? Yes No
Back-up of toilets? Yes No
Back-up of any 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:
• Ensure that the septic tank(s), distribution box(es),and/or seepage pit(s), if any,will be uncovered
prior to the requested inspection time;
• Have a septage hauler on site(to pump the tank after*the inspector verifies flow from fixtures);
➢ Tank must be pumped in presence of inspector
• Have an authorized representative present at the site;
• Allow the inspector to verify information provided above, and to conduct an inspection of the
indicated onsite wastewater treatment system(s), including all system components and interior
plumbing in crawl spaces and basements.
To the best of my knowledge,the information provided above is accurate.
I agree to be responsible for inspection fee payment.
Signature of property owner or authorized agent
Please print name: &4�/ EFkAma
Affiliation. �u agent
Signatur Date: f
Prior to scheduling with the Town of Oueensbury,You MUST:
1. Schedule a sewage hauler to be on site to pump tank while inspector is on site.
Hauler should arrive 30-45 minutes after scheduled time with the Town of Queensbury's
Code Enforcement Officer.
2. Expose inlet and outlet of tank, expose d-box, expose any seepage covers.
Building&Code Enforcement January 2019
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DATE D//D8/2019
February 2 2019
Dear Mr Hatin
Please be advised I am the buyer of 20 Brayton Rd and assume all financial and
contstruction costs associated with the installation of a new 3 bedroom septic system
to be located on the property. I have enclosed a check for$2000 to be held in escrow
until all septic work has been completed. The owner of record upon completion of sale
will be 20 Brayton LLC 308 Lenox Rd Richmond MA 01254 413-717-1010
Regards
}
Don Bernard
20 Brayton LLC
1