application •
Office Use Only
J . ,
` 5',) Permit#: Pr— b21-9-Zmao
Town of(Ziccnsbun• Fee: 2
742 Bay Road,Queensbury,NY 12804
P:518-761-8206 or 518-761-8205 Invoice#: 12-tob I
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: 4 LLy L4\1
Tax map number: Z 9. 12 Z- L0- -
Property owner: W 1111 co, P t Farm ktjk S Q—Q. --11 s
Mailing Address (c/s/z): , z1 ('aw-4 (2-r' ,[t'D R 1 N y i2-.
Cell#: 516 - 2-taO - t -Y}11 and Line#: 5l8 - .1 o
Email: ?fp Pt-RSA' (-- p L®w`
**PLEASE SEE SEPARATE PAGE FOR EXEMPTIONS**
Household Information:
#Bedrooms 1\ #Bathrooms 3 #Kitchens 2- Jacuzzi tub(s) 4 Garbage grinder
Onsite Wastewater Treatment System: ?12- L1 S OECEOWEB
How::::= :: ;;
throp 1
1
till ,
Year ize of Septic Tank 100 6 JUN 1 0 2020
Type of Absorption System: TOWN OF OUEENSEi1RY
BUILDING.. CO%+rS
Are all system components wholly within the property boundaries? AYes ❑ o - __.._•-
Are system plans available? ❑ Yes ❑ No
Does the system(s) serve multiple properties? ❑ Yes >3 No
If yes, describe
Maintenance:
Service agreement? ❑ Yes No If yes, vendor name
Date of last inspection 2 D1l- N/A ❑ Date tank last pumped 26\1-N/A ❑
Frequency of pumping N/A ❑
1\rnenv—
roperty Transfer Packet Revised October 2019
"k; l 1-.
. List known repairs/replacements, with dates:
Date Type of Repair/Replacement
2 oi0,0/9.. -i7-11, \...3\ ---N -v.. '4./....=cea3k...-7 \-k-u1/45--e)
w 2:t u\[..
Operation:
• System problems? Yes 'x No
• Sewage odors? Yes X No
• Direct surface discharge(s)? Yes k No
• Back-up of toilets? Yes Xc No
• Back-up of any other fixtures? (e.g. slow drains) Yes )C No
• Seasonal ponding or breakout of leach field? Yes �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 aftee 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: \r-MuAL‘,-‘ ' SZ-(.9z.- -S,
Affiliation: X owner
agent
Signature: L-,\A (--- 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 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
1
Property Transfer Sewage Disposal Information Form
ECl [r
Town of Queensbury
742 Bay Road,Queensbury,NY 12804 JUN 1 0 2020 Y Date:
P:518-761-8256 www.queensbury.net i —
TOW`� , ?UEENSEURY
i�VP
To: '\ �-��-L t� �- � `_`" . a�:;�`- —
(Name of Applicant)
Re: Onsite Wastewater Treatment System Inspection Information Request for:
y \ \ � �---� C' k.3
(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. We require 48 hours notification prior to inspections. If you have any
questions, please call. You may FAX or email the completed Septic System Inspection Information form back
to us.
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 within 6 months of the date of this application or June 1st of the
current, or following calendar year (whichever comes first), a map locating the septic system and payment
totaling$2250 ($2000 refundable deposit plus$250 permit fee).
Phone: (518) 761-8256 Fax: (518) 745-4437 Email: kated@queensbury.net
Thank you.
Sincerely, Kate Deck
Office Specialist
Building&Codes
4 oft, TOWN OF QUEENSBURY
�rr�1�
"Home of natural beauty...a good place to live."
David Hatin, Director
Building and Code Enforcement -
Town of Queensbury. 742 Bay Road
Office:(518)761=8256- - _ Queensbury,NY 12804
www.queensbury.net . kated@queensbury.net
Property Transfer Packet 2019
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