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applicationsSEWAGE DISPOSAL SYSTEM INSPECTION INFORMATION Individual Residential Wastewater Treatment System Property and Owner Information:(Please attach property survey or tax parcel map) Property address:226 Lake Parkway :TreTaxmapnumber:226.19-89-1 _IRECGEEDN=|‘iPropertyowner:Jason Maynard ; oy —1 |JAN 07 2020 Mailing Address (c/s/7)guy Cell #;206-939-2445 i TOWN ELandLine#: Email:jasonmaynard@icloud.com **PLEASE SEE SEPARATE PAGE FOR EXEMPTIONS** Houschold Information: #Bedrooms 5 #Bathrooms6_—#Kitchens 1_—Jacuzzi tub(s)9 ___Garbage grinder____ Onsite Wastewater Treatment System: How many systems are on the property?1 ‘Year system(s)installed:Tank 2095 Size of Septic Tank 1900 gallon ‘Type of Absorption System:[each field Are all system components wholly within the property boundaries?@Yes C1 No Are system plans available?Yes No Does the system(s)serve multiple properties?[1 Yes {No Ifyes,describe Maintenance: Service agreement?(Yes (4 No If yes,vendor name Date of last inspection N/A 1)Date tank last pumped_N/A 0 vAFrequencyofpumping Property Transfer Packt Revised October 2019 List known repairs/replacements,with dates Date ‘Type of Repair/Replacement Operation: +System problems?Yes x__No +Sewage odors?Yes X__No +Direct surface discharge(s)?_Yes X__No +Back-up of toilets?Yes ¥No +Back-up of any other fixtures?(e.g.slow drains)Yes X__No +Seasonal ponding or breakout of leach field?Yes X No Statement of Acceptance of Conditions: Lagree 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 theindicatedonsitewastewatertreatmentsystem(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 and I acknowledge the following:fier |year from date of submission and there is no activity on this permit,the permit will expire and will be subject to submission of a renewal application and payment of the renewal fee based on the current fee schedule.All fees must be paid PRIOR TO SCHEDULING any inspections.In addition,if the permit iswithdrawn20%of the fee is retained by the Town of Queensbury. Signature of property owner or authorized agent Please print name:_J@son Maynard Affiliation: 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’sCodeEnforcementOfficer. 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 October 2019, EXEMPTION CONDITION OPTIONS Due to one of the conditions listed below,I am requesting an exemption from the Septic Inspection Upon Property Transfer by the Town of Queensbury: Oo The property to be sold or transferred will not be inhabited,and the new owner plans to demolish the existing structure.In order to qualify for the exemption,a notarized affidavit must be submitted to the Building and Codes Enforcement Office stating thatthe dwelling will not be inhabited and that it will be demolished with no immediate plans to rebuild or the dwelling will not be inhabited,it will be demolished and rebuilt,in which case the affidavit shall be accompanied by a site plan,including adequate detail to demonstrate a lawful OWTS,together with a check payable to the Town of Queensbury in the amount of $2,000.Such funds will be held in a non-interest-bearing escrow account. and will be released,in the former case,upon issuance of a demolition permit and,in the latter case, upon issuance ofa certificate of compliance from the Building and Codes Enforcement Office.If the Property Transfer inspection is not completed within that 6 (six)month timeframe, the $2000 will be forfeited. ‘An OWTS inspection was not able to be completed prior to the conveyance of real property due to inclement weather.In order to qualify for the exemption,a notarized affidavit from the new property ‘owner to complete the requisite OWTS inspection within six months of the date of the conveyance of real property,or June 1,whichever comes first,must be filed with the Building and Codes Enforcement Office.A check payable to the Town of Queensbury in the amount of $2,000 will be held in a non- interest-bearing escrow account and shall be released upon the completion of a satisfactory OWTS inspection from the Building and Codes Enforcement Office.If the Property Transfer inspection is not completed within that 6 (six)month or June 1*timeframe,the$2000 will be forfeited. The property to be sold or transferred contains an existing OWT that does not comply with the provisions of this article,and the prospective purchasers and/or the Seller wish to forgo an inspection in favor of installing an approved OWTS within six months of the transfer of property.In order to qualify for the exemption,a notarized affidavit must be submitted to the Building and Codes Enforcement Office stating that the existing OWTS will be replaced within six months from transfer of property.The affidavit must be accompanied by a site plan,including adequate detail to demonstrate thatthe replacement OWTS will comply with this article,together with a check payable to the Town of Queensbury in the amount of $2,000.Such funds will be held in a non-interest-bearing escrow account and will be released upon issuance of a certificate of compliance from the Building and Codes Enforcement Office.If the Property Transfer inspection is not completed within that 6 (six)month timeframe,the $2000 will be forfeited. Property Transfer Packet Revited Ostber 2019 C1 During the OWTS inspection,afailureofthesepticsystemwasdetermined.Due to winter andfrozenconditions,the repair to an existing OWTS could not oceur or a new OWTS could not beinstalledbeforetheconveyanceofrealproperty.In order to qualify for the exemption,a notarizedaffidavitfromthenewpropertyownertocompletetheinstallationorrepairofthesepticsystemwithinsixmonthsfromthedateoftheconveyanceofrealproperty,or June 1,whichever comes first,must befiledwiththeBuildingandCodesEnforcementOffice.A check payable to the Town of Queensbury intheamountof$2,000 will be held in a non-interest-bearing escrow account and shall be released uponthecompletionoftherepairorinstallationofanewsepticsystemandasatisfactoryOWTinspectionfromtheBuildingandCodesEnforcementOffice.If the Property Transfer inspection is notcompletedwithinthat6(six)month or June 1*timeframe,the $2000 will beforfeited. C1 There's record of the property's OWTS having passed Town inspection within the last three years.Please provide a copy of this record PLEASE READ NOTICE THOROUGHL’ Failure to complete the inspection,obtain the permit or complete all repairs/installationsidentifiedintheprecedingsubsectionsofthissectionwithinthetimeprovidedoranysubsequentdeadlineestablishedbytheBuildingandCodesEnforcementOfficewillresultinfo moneys held in escrow,and the Town may use such funds toward abating the conditions caused by each such violation of this article. Inspections must take place within one (1)year of submission of a completed application,Inspections scheduled to take place after the one year period will be subject to submissionofarenewalapplicationandpaymentoftherenewalfeebasedonthecurrentfeeschedule. Thave read and understand the above notice regarding the expectations and possible forfeitureofmoneyssubmittedtothe‘Town of Queensbury for an exemption request. eller: Print Name:Jason Maynard Date: sien Name: aoe eee Date:Taal,Loto Buyer: Print Name:David Prescott for Prescott Holding Company -Date:_ Sign Name:a Date: Property Transfer Past Revisad October 2019