application roil\
`^ Property Transfer Sewage Disposal Information Form
Town of Queensbury
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net
Date: / 4/ 1P
To: C'
(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.
Sincerely,
(8 .04,1 ,, i [PCEOVE0
IAFEB 0 6 2019
TOWN OF QUEENSBURY
Dave Hatin BUILDING&CODAS
Director of Building and Code Enforcement
Town of Queensbury
Building&Code Enforcement January 2019
Office Use Only
Permit#: P1 005(0 -2a loi
742 Bay Road,Queensbury,NY 12804 Fee: 2
P:518-761-8206 or 518-761-8205 www.queensbury.net L1 b
Invoice#:
SEWAGE DISPOSAL SYSTEM INSPECTION INFORMATION
Individual Residential Wastewater Treatment System
Property and Owner Information: (Please attach property survey or tax parcel map)
Property address:
Tax map number: 6 f9 • / /3
Property owner: ' -7'
Mailing Address (c/s/z): �/ �.�' ', "2«/ � Fe /2g
Cell#:.6-7 .w-2 2•- 3///0- Land Line#: --
Email: P ,7/c!n
Household Information:
#Bedrooms C #Bathrooms 5 #Kitchens
Onsite Wastewater Treatment System:
How many systems are on the property? I
Year system(s) installed: Tank Size of Septic Tank /2!:, ''
Type of Absorption System: 4_.. 'E ., -'-
Are all system components wholly within the property boundaries? � Y es No
Are system plans available? Yes No
Does the system(s) serve multiple properties? Yes €No
If yes, describe
Maintenance:
Service agreement? Yes /No If yes, vendor name
Date of last inspection6''/-17 N/A Date tank last pumped N/A
Frequency of pumping N/A
Building&Code Enforcement January 2019
ListNknowx repairs/replacements, with dates:
Date Type of Repair/Replacement
Operation: /
System problems? Yes Y No
• Sewage odors? Yes V.
No
• Direct surface discharge(s)? Yes V No
• Back-up of toilets? Yes
• Back-up of any other fixtures? (e.g. slow drains) Yes V 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: / d //),I 7 a I, '
Affiliation: owner agent
Signature: / Date: /
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 tank, expose d-box, expose any seepage covers.
Building&Code Enforcement January 2019