application Property Transfer Sewage Disposal Information Form
Du
Town of Qyeensbury Date: /9
742 Bay Road,Queensbury,NY 12804 'ra 11 7\TEM
19
P:518-761-8256 www.queensbury.net
TOW C)
To: VT / ��ame of Applicant)
Re: Onsite Wastewater Treatment System Inspection Information Requ st for:
/.//#6 de,1,4-/Yeila/ta
(Site Addr
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. We require 48 hours notification prior to inspections. If you have any
questions, please call. You may FAX or email the completed Septic System Inspection Information form back
to us.
If the purchaser is requesting an exemption, please submit this application along with a notarized letter stating
the septic system will be inspected or repaired within 6 months of the date of this application or June 1st of the
current, or following calendar year (whichever comes first), a map locating the septic system and payment
totaling $2250 ($2000 refundable deposit plus$250 permit fee).
Phone: (518) 761-8256 Fax: (518) 745-4437 Email: kated@queensbury.net
Thank you.
Sincerely,
j 4 .4
T
David Hatin, Director
Building and Code Enforcement
Town of Queensbury
Property Transfer Packet Revised March 2019
` 'OWOffice Use Only
Permit#: t" r // /9
.4 et rI.:,otibtirt Fee: 2<0 Qi"
742 Bay Road,Queensbury,NY 12804
P:518-761-8206 or 518-761-8205 Invoice#: /`f'ii
SEWAGE DISPOSAL SYSTEM INSPECTION INFORMATION
Individual Residential Wastewater Treatment System
Property and Owner Information: (Please attach property survey or tax parcel map)
Property address: 7 L t J E i ewri a
e/ /V 1
Tax map number: `T `7 1- / 3
Pro ert owner: Not& tlodll
_
Mailing Address (c/s/z): Po Bex ,2 -I / Gler'i de_ NI/2 g0.CO
Cell#: ,51/- 7iv-al Land Line#: g-6��-� qoo,
�sce D,:i i-----L- - - ---
��.
Email: /l�7" /71�/�, � .,,, ,, d F/ „ , g
v
'MAY Household Information: t�,ow o u 1 2G ig
# Bedrooms 4- #Bathrooms ' #Kitchens 1 OV,/ 5 �F 0'i� :PiSBURY
CO1y MMU'..;' 1 0 MENT
Onsite Wastewater Treatment System:
How many systems are on the property? /
Year system(s) installed: Tank)668 Size of Septic Tank /52,6
Type of Absorption System: `„:, ✓ 04/Q l / .—% f
Are all system components wholly within the property boundaries? IRIYes ❑ No
Are system plans available? kl Yes ❑ No
Does the system(s)serve multiple properties? ❑ Yes LRLNo
If yes,describe
Maintenance:
Service agreement? Ad Yes ❑ No If yes,vendor name
Date of last inspection��//®/I N/A ❑ Date tank last pumped9/ N/A ❑
Frequency of pumping r�, f /A ❑
Property Transfer Packet Revised March 2019
List known repairs/replacements,with dates:
Date Type of Repair/Replacement
Operation:
+ System problems? Yes X No
• Sewage odors? Yes k No
• Direct surface discharge(s)? Yes X. No
+ Back-up of toilets? Yes X, No
• Back-up of any other fixtures?(e.g. slow drains) Yes X No
• Seasonal ponding or breakout of leach field? Yes 3( 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 pa�u)thoorized agent
4i Please print name: V`-' 0I� 1/(•�i4' /91 S
Affiliation: ,4 owner agent
j�� F
Signature: J/(Jidre- 1'/
Date: / / l 9
Prior to scheduling with the Town of Queensburv,von 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 septic tank, and/or pump station, expose d-box, expose
any seepage pit covers.
3. Excavate test hole in leach field if there is no d-box.
Property Transfer Packet Revised March 2019