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application Office Use Only , r' Permit#: PT— © l �lij Tummll ciQyccnctwnvt Fee: 2 c O- 742 Bay Road,t ueensbury,NY 12804 R;518-7618206 or 518-761 8205 Invoice#: 19-1-1- www aueensburv'net SEWAGE 1 ISPOSAL_SYSTEM INSPECTION INFORMATION Individual Residential Wastewater Treatment System Property and Owner Information: (Please attach property survey or tax parcel map) FrpPerty address: ,c- Cn- ad C 1✓e( 4'_Ay 42 eaad Tax map number: Z?t/._/_la-_/- Property owner: _&2 /C.,e )e/i/ia c._ f/ll/ � Mailing Address(c/s/z) ,75 _P d eLS / R art_ E dtElel_'t --C O/a("/..? . Cell#:cd - S o _3 � � `7< �� -•_ - — , Land Line#: a d,�-o?S.5_ P . /_ -.--- Email: /IN Ke`/yet9 9 l /itCc'!i-e7'/ , Ae Household Information: J #Bedrooms .2__ #Rathrooms V #Kitchens / I I A-, rows 4 3 ?019 Onsite Wastewater Treatment:System: 130/4 PCk/ How many systems are on the property? / Year system(s) installed: Tank2Od' Size of Septic Tank /,5 dc) Type of Absotption.System: L-` 'U ' , Are all system components wholgwithin the property boundaries? ryes D No Are system plans available? VI Yes O No Does the_systein(s)serve Multiple-properties? ❑ Yes VNo If yes,describe Maintenance: Service agreement? 0 Yes 'tkiNo If yes,vendor name . _ __ Date of last inspection N/A lid Date tank last pumped N/A1 Frequency of pumping - N/A [i Property Transfer_Packet Revised March 2019 List known repairs/replacements,with dates: Date Type of Repair/Replacement Operation: • System problems? Yes el No • Sewage odors? Yes SC No • Direct surface discharge(s)? Yes k No • Back-up of toilets? Yes u No • Back-up of any other fixtures?(e.g.slow drains) Yes ( No • Seasonal ponding or breakout of leach field? Yes V 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: t(' rie Affiliation: wner ag t ViC y1�'P , i)1. t9 Signature: fu ql— G� Date: /S/ Prior to scheduling with the Town of Oueensburv,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 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 Property Transfer Sewage Dis osal Information Form Town of Queensbury Date:- J/_c/o2t'i 9 742 Bay Road,Queensbury,NY 12804. P:,118=761-8256 tivwvw:queensburYnet. TO: 746(1 —/ / /y (NameofApplicant) Re Onsite.Wastewater Treatment System Inspection Information Request for: :. 3. sor_,_..v 4 di:CL_ev/ d4.-i _ /1� - / -z - - (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 Inspettifn 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'requestirg an exemption, please submit this application along with a notarized letter stating the septic system will be inspected or repai rred 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($20.00 refundable depositplus$.250 permit fee). Phone: (518)761-8256 Fax: (518)745-4437 Email: skated@queensbury.net Thank you. Sincerely, David Hatin Director Building and Code Enforcement Town of.Queensbury Propeity Transfer;Packet Revised March 2019