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application 4 Office Use Only Permit#: f oboc► ' 2-4 L� Town of f uecn b ry Fee: Z� 742 Bay Road,Queensbury,NY 12804 P:518-761-8206 or 518-761-8205 Invoice#: 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: LEG7.61•/721W// /)/Q; 1/% , clU leY Tax map number: 39- 7 Property owner.' n Mailing Address (c/s502/71-71A �CQ,� � ot�D�j ,, i YE. vWA, 50ac c)/ Cell#:L57 79Gy-���� Land Line#s 5 /$�795 - '7c ' � � f Email: **PLEASE SEE SEPARATE PAGE FOR EXEMPTIONS** Household Information: #Bedrooms #Bathrooms- #Kitchens / Jacuzzi tub(s) 0 Garbage grinder Onsite Wastewater Treatment System: How many systems are on the property? Year system(s) installed: TankYeslize of Septic Tank/CC03r92 NCO 94=?L /np li=ram Type of Absorption System: cJj,i / Al .2-71D / Sp Are all system components wholly within the property boundaries? ❑Yes ,No t1 bS 7%DA(&Q/ Are system plans available? a Yes 0 No Vf:›l��cp47 -47 ��c/\®i�i"F+ Does the system(s) serve multiple properties? ❑ Yes No If yes, describe Maintenance: Service agreement? 0 Yes 19:l No If yes, vendor name AVA Date of last inspectii'ieobA N/A El Date tank last pumped N/A g Frequency of pumping N/AX1 Property Transfer Packet Revised October 2019 List known repairs/replacements, with dates: Date Type of Repair/Replacement ,alto/ c Operation: • System problems? Yes N, No • Sewage odors? Yes No • Direct surface discharge(s)? Yes . ' No • Back-up of toilets? Yes ,/ No • Back-up of any other fixtures? (e.g. slow drains) Yes ✓ 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 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: owner agent t_��.r 3.yam s . /iL�71�`i . Signature4 �- Date: Col t5120 o 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 October 2019 Property Transfer Sewage Disposal Information Form Y _.�1 • Town of Queensbury Date: 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.queensbury.net Ck: -.S QM-'f /7,on/ °©ep . (Name of Owner/Applicant) Re: Onsite Wastewater Treatment System Inspection Information Request for: 3 G/9 /././/9 (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 1St 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. lcEll Sincerely, JUN 19 2020 I TOWN OF QUEENSBURY fir.. \ BUILDING&CODES David Hatin, Director Building and Code Enforcement Town of Queensbury Property Transfer Packet Revised February 2020