application (it 1D ECEOVE5 Office Use Only
Permit#: er_
Fee: ZS'U. dD
742 Bay Road,Queensbury,NY 12804 SEP 10 2019 Z Gl�U
P:518-761-8206 or 518-761-8205 - Invoice#:
www.queensbury.net TOWN OF QUEENSBURY
SEWAGE DISPOSALS SF - ` r"'T^RMATION
Individual Residential Wastewater Treatment System
Property and Owner Information: (Please attach property survey or tax parcel map)
Property address: 116 Lake Parkway
Tax map number: 226.15-4-14
Property owner: Arthur&Alison Birney Contact: Lex Birney (Daughter)
Mailing Address (c/s/z): 4846 Van Ness Street NW Washington, DC 20016
Cell #: 410-991-5452 Land Line #: 443-951-2005
Email: Ibirney@thebrickcompanies.com
Household Information:
# Bedrooms 4 # Bathrooms 3 1/2 # Kitchens 1
Onsite Wastewater Treatment System: (See Queensbury Permit File 96-125)
How many systems are on the property? 1
Year system(s) installed: Tank 1996 Size of Septic Tank 1,250 gallons
Type of Absorption System: Pipe in Stone Trenches
Are all system components wholly within the property boundaries? l lYes ❑ No
Are system plans available? 0 Yes ❑ No
Does the system(s) serve multiple properties? ❑ Yes 0 No
if yes, describe
Maintenance:
Service agreement? ❑ Yes m No If yes, vendor name
Date of last inspection N/A ® Date tank last pumped N/A
Frequency of pumping N/A m
Property Transfer Packet Revised March 2019
List known repairs/replacements, with dates:
Date Type of Repair/Replacement
Operation:
• System problems? Yes I No
• Sewage odors? Yes V- No
• Direct surface discharge(s)? Yes 7-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 1 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; im-5 [;,N CAN£ t'tn)6 j 1`C F-4 tA15
Affiliation: owner agent_______Ch<;)t
Signature: Date: 4
Prior to scheduling with the Town of Queensbury, 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