application k' 1
Office Use Only
Permit#: O lcAb- ?-Ez)q
Town of Qurensbury
742 Bay Road,Queensbury,NY 12804 Fee: 22'
P:518-761-8206 or 518-761-8205 www.queensbury.net
Invoice#: I��O
SEWAGE DISPOSAL SYSTEM INSPECTION INFORMATION
Individual Residential Wastewater Treatment System
Property and Owner Information: (Please attach property survey or tax parcel map)
Property address: 53 /a�i5016z y Pei, r y
Tax map number: ;3 7, /g2 A2 — / (�
Property owner: c O/2E7.4 L lN,1,
Mailing Address (c/s/z): 07'2 A p6r 6LWW$Mus A//' /2ID/
Ce11#: Land Line#: ,�/ - /29. - '76
Email:
Household Information:
#Bedrooms / #Bathrooms / /2 #Kitchens / 1ECIEOVE
APR 0 9 2019
Onsite Wastewater Treatment System:
TOWN OF QUEENSBURY
BUILDING&CODES
How many systems are on the property?
Year system(s) installed: Tank 7 Size of Septic Tank 2 a a t 4U4'
Type of Absorption System: L !- ,r z-z-
Are all system components wholly within the property boundaries? 1'Yes No
Are system plans available? Yes trNo
Does the system(s) serve multiple properties? Yes '✓ No
If yes, describe
Maintenance:
Service agreement? Yes Vo If yes,vendor name
Date of last inspection 0,2U/67 N/A Date tank last pumpeda2e)/6 N/A
Frequency of pumping �f/Z-- 3 - ye S N/A
Property Transfer Packet Revised February 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 I,No
• Back-up of toilets? Yes /'No
• Back-up of any other fixtures? (e.g. slow drains) Yes 11\lo
• Seasonal ponding or breakout of leach field? Yes t/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: L022'7774- L A4m2,
Affiliation: owner agent
Signature: Date: /1l41/
Prior to scheduling with the Town of Oueensbury, 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 February 2019
•
AFFIDAVIT
STATE OF NEW YORK )
COUNTY OF WARREN ) ss.:
Loretta Landry, being duly sworn, deposes and says that:
1. I, Loretta Landry, residing at 277 Ridge Street, Glens Falls,New York, am the owner of
the property known as 53 Assembly Point Road,Lake George,New York and I make this
affidavit to request an extension of time to have the Town of Queensbury conduct the
Onsite Wastewater Treatment System Inspection at the property known as 53 Assembly
Point Road,Lake George,NY. •
2. I have entered into a contract with William and Kathleen S. Bosy on March 4, 2019, to
sell my property located at 53 Assembly Point Road, Town of Queensbury, County of
Warren, State of New York.
3. I am submitting an application for a sewage disposal system inspection to the Town of
Queensbury with the requisite application fee of$250, but due to cold weather conditions
is unable to safely have the system inspected at this time. I am also depositing the sum of
$2,000 with the Town of Queensbury to hold in escrow until such time as the new owners
order the necessary inspection.
4. It is my intention to close the sale of the aforementioned property prior to the weather
permitting a safe inspection of sewage disposal system so the new owner, William and
Kathleen Bosy will contact the Town of Queensbury prior to June 1, 2019 to request the
inspection be performed.
Dated:'1/z//f,9
Lor a Cr2jv
STATE OF NEW YORK)
COUNTY OF WARREN)ss.:
On this day of /21-4- in the year 2019, before me, the undersigned, a Notary
Public in and for said state, personally appeared LORETTA F. LANDRY, personally known to
me or provided to me on the basis of satisfactory evidence to be the individual whose name is
subscribed to the within instrument and acknowledged to me that she executed the same in her
capacity, and that by her signature on the instrument, the individual, or the person upon behalf of
which the individual acted, executed the inst t.
N y Public
DANIEL J. MANNIX
Notary Public State of New York
No. 02MA6044847
Qualified in Warren Coun
Commission Expires July 17, Q i"
AFFIDAVIT
We, WILLIAM J. BOSY,JR. and KATHLEEN S. BOSY,being duly sworn deposes and
says:
1) We are over the age of 18 years,having a mailing address of PO Box 1, Lake
George and are the purchasers in a contract dated March 4,2019 for real property
located at 53 Assembly Point Road,Town of Queensbury, Warren County,New
York. This statement is given under the penalties of perjury with the
understanding that the seller and the Town of Queensbury will justifiably rely
upon the representations herein made.
2) The current owner, Loretta Landry, has submitted an application for a sewage
disposal system inspection to the Town of Queensbury with the requisite
application fee of $250, but due to cold weather conditions is unable to safely
have the system inspected at this time.
3) We make this affidavit in support of Loretta Landry's request for an extension of
time to have the Town of Queensbury conduct the Onsite Wastewater Treatment
System Inspection at the property known as 53 Assembly Point Road, Lake
George,NY.
4). It is our intention to close the purchase transaction of the aforementioned property
prior to the weather permitting a safe inspection of sewage disposal system and
hereby affirm that we will contact the Town of Queensbury prior to June 1, 2019
to request the inspection be performed.
,4Dated: J
LIA , .
THLEEN S. BOSY
STATE OF NEW YORK) Y
COUNTY OF WARREN) ss.:
On this 3 c\ -day of c\p,',1 anct in the year 2019, before me, the undersigned,
personally appeared WILLIAM J. BOSY, JR. and KATHLEEN S. BOSY, personally
known to me or proved to me on the basis of satisfactory evidence to be the individuals
whose names are subscribed to the within instrument and acknowledged to me that they
executed the same in their capacity, and that by their sib es on the instrument, the
individuals, or the person -upon behalf of which the i3t,iv, ual ed, executed the
instrument. - -_ 4
_ (1."
-- -. Notary Public
_ - - NOTARY PUBLIC IN THE STATE OF l\Ii .;: ORK
- - l LUFlEO-N SARATOGA COUNTY.NO.01M 47060
L9Y COMPSSION EXPIRES FEB.2,2CAZZ