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applicationProperty Transfer Sewage Disposal Information Form Town of Queensbury 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.queensbui BUILE West intSaxcth ic (Name of Owner/Applicant) Re:Onsite Wastewater Treatment System Inspection Information Request for: 103 Lave Drkway ,Lake George,VY 24S (Site Address) Thank you for requesting an inspection for the onsite wastewater treatment system (OWTS)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 advanced information about the site.Prior to our inspection,we request this completed application,a site map indicating the location of the septic components and confirmation the pre-inspection preparation (see the last page of this packet)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,with the appropriate fee(s)and documentation,prior to scheduling an inspection. Please note the Town of Queensbury’s fee for this service is $250.Be advised that all fees must be paid prior to scheduling the inspection.We require 48 hours notification prior to scheduling the inspection. 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/replaced within 6 months from the date of the Property Conveyance or June 1%of the current,or following year (whichever comes first),a map locating the septic system and payment totaling $2250 ($2000 refundable deposit plus $250 permit fee).The deposit is forfeited if the owner fails to complete the repairs or installation as stated above. If you have any questions,please call. Phone:(518)761-8256 Email:kated@queensbury.net Thank you. Sincerely,Dab A Yd- David Hatin,Director Building and Code Enforcement Town of Queensbury Property Transfer Packet Revised October 2019 Office Use Onl Permit it:_PT=OXV2=COLY fom of ree:_#2,280,O 742 Bay Road,Queensbury,NY 12804 P:518-761-8206 or 518-761-8205 Invoice #:_RITE www.queensbury.net SEWAGE DISPOSAL SYSTEM INSPECTION INFORMATION Individual Residential Wastewater Treatment System Property and Owner Information:(Please attach property survey or tax parcel map) Property address:108LakefobLakeamMYpedo ‘Tax map number:eit hPropertyowner:___WES" Mailing Address (c/s/2):rh 00 ceil #:203 T4S-584)Land Line #: Email:Kretta West-faun lymai)com **PLEASE SEE SEPARATE PAGE FOR EXEMPTIONS** Household Information: #Bedrooms #Bathrooms #Kitchens Jacuzzi tub(s)_—__Garbage grinder aE Onsite Wastewater Treatment System: How many systems are on the property?_|__ Year system(s)installed:Tank___Size of Septic Tank _‘Type of Absorption System: Are all system components wholly within the property boundaries?Yes (No Are system plans available?_O Yes 1 No Does the system(s)serve multiple properties?C1 Yes {®No Tfyes,describe Maintenance: Service agreement?(1 Yes {No Ifyes,vendor name Date of last inspection N/A C1 Date tank last pumped NAG Frequency of pumping wag Property Transfer Packet Revised October 2019 List known repairs/replacements,with dates: Date ‘Type of Repair/Replacement Operation: +System problems?__Yes _¥No +Sewage odors?___Yes No +Direct surface discharge(s)?___Yes No +Back-up of toilets?___Yes _y No +Back-up of any other fixtures?(e.g.slow drains)___Yes No +Seasonal pondingor breakout of leach field?___Yes No Statement of Acceptance of Conditions: T 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 and I acknowledge the following: After 1 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 is withdrawn 20%of the fee is retained by the Town of Queensbury. Signature of property owner or authorized agent Please print name: Affiliation:agent Signature:Date:(2/2, Prior toScheduling 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 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: ie ‘The property to be sold or transferred will not be inhabited,and the new ownerplans 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 that the 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 of a certificate of compliance ftom 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 ‘ownerto 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 OWTS 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 that the 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 Revised October 2019 1 During the OWTS inspection,a failure of the septic system was determined.Due to winter and frozen conditions,the repair to an existing OWTS could not occur or a new OWTS could not be installed before the conveyance of real property.In order to qualify for the exemption,a notarized affidavit from the new property owner to complete the installation or repair of the septic system within six months from 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 the repair or installation of a new septic system and 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. (1 There is 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 THOROUGHLY: Failure to complete the inspection,obtain the permit or complete all repairs/installations identified in the preceding subsections of this section within the time provided or any subsequent deadline established by the Building and Codes Enforcement Office will result in forfeiture of the 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 submission of a renewal application and payment of the renewal fee based on the current fee schedule. Thave read and understand the above notice regarding the expectations and possible forfeiture of moneys submitted to the Town of Queensbury for an exemption request. Sale Gul Hest pas efi Date:2/3514SignName: Buyer: Print Ni Date: Sign Name:Date: Property Transfer Packet Revised October 2019 A —|STATE OF NEW YORK +|| |DEC 23 2019|| COUNTY OF WARREN ) AFFIDAVIT IN COMPLIANCE WITH ai 137-4€OF THE TOWN ok - QUEENSBURY Cope | | DWN OF NSBURY | I,Brett West,residing at 4651 Gulf Shore Bivd;Unit 104,Naples,Florida,34103,and being duly sworn,deposes and says that: 1,Lam a member of West Point South LLC,the owner of the premises known as 108 Lake Parkway in the Town of Queensbury. 2.West Point South LLC closed on the purchase of the property on October 10, 2019. ‘The dwelling located on the premises will not be inhabited and it will be demolished with no immediate plans to rebuild. 4.Lhave contracted for the demolition of the home and removal of the existing septic system and I expect this to occur within two weeks of the date of this, affidavit. aes 1/4 : Dated Brett West MAPIA A CAGLIARDI ui of New YorkBEe:uncomsyi We? Sworn to before me this ep24day of _D&emby 2019