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PT-0627-2019 w Property Transfer Sewage Disposal Information Form 1 , Giwn of(Zueensbury Date: y.- /3 -/? 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 iIWsv -L:eers4,.r-, _ To: Môc alit 4(.4( A- J gig/14,-1 c . (Name of Applicant) Re: Onsite Wastewater Treatment System Inspection Information Request for: , z ? /fe ,ed (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$250 permit fee). Phone: (518) 761-8256 Fax: (518) 745-4437 Email: kated@queensbury.net Thank you. iivr......._ Sincerely, E c 1 el C- AstO i Igo(1--' SEP 13 2019 David Hatin, Director TOWN OF . Building and Code Enforcement BUl1 QUEENSLURY DING& BODES Town of Queensbury Property Transfer Packet Revised March 2019 ' -t� EOd L�' []1 Office Use Only SEP 13 2019 Permit#: '" tic2r- 2QAQI r„»n ltbtann n rE Fee: 1 TOWNS OF QljELN�B SRY dQ 742 Bay Road,Queensbury, NY 128 BJ! DiNG, ^t P:518 761 8206 or 518 761-8205 Invoice#: 2©16 SEWAGE DISPOSAL SYSTEM INSPECTION INFORMATION Individual Residential Wastewater Treatment System Property and Owner Information: (Please attach property survey or tax parcel map) Property address: / 2 7 SP lye oe l Tax map number: 2 Z 7. J 7 - / - S? Property owner: ,12/c i / r5 ,/,/,uf r L L C Mailing Address(c/s/z): c— /22 yf" Cell #: S/7- ,��/ J/7.r Land Line #: “S/13'`i‘g - 27?7 Email: One1lee C v450-6ov✓7 fey h f nee t o 7'111 - /o %o✓vI ;,u/k o/d Se(4� S y../c 14.4 6c.4 "--c. Household Information: Net.-i t t *fie y wt ibyolr cl J .$E.4 `` FIr 1 # Bedrooms Z # Bathrooms I # Kitchens Onsite Wastewater Treatment System: How many systems are on the property? Year system(s) installed: Tank PAW- Size of Septic Tank Type of Absorption System: A,ac Are all system components wholly within the property boundaries? L Yes ❑ No Are system plans available? ❑ Yes to Does the system(s) serve multiple properties? ❑ Yes No If yes,describe Maintenance: Service agreement? ❑ Yes If yes, vendor name Date of last inspection N/A 1p Date tank last pumped N/A 01) Frequency of pumping N/A lIF Property Transfer Packet Revised March 2019 List known repairs/replacements, with dates: Date Type of Repair/Replacement /I)P 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 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. I agree to be responsible for inspection fee payment. Signature of property owner or authorized agent Please print name: taCA, D. L Affiliation: owner agent Signature: 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 Dennis L. Dickinson, LS/PE ICKINSON (TEL) 518-6G8-4G76 Devin T. Didunson dldickmson78@gmail.com ASSOCIATES SURVEYORS* ENGINEERS* LAND CONSULTANTS Location: 30 Stone Schoolhouse Road Mail: P.O. Box 388, Lake George, New York 12845 lECEll 'WEri- 16 July 2020 D 11 JUL 2 Z 2020 I Mark Smith, Building Inspector r l Town of Queensbury TOWN OF QUEENSBURY 742 Bay Road BUILDING&CODES Queensbury, New York 12804 RE: Septic Inspection Dear Mark: On 13 July 2020 I performed (2) percolation tests in the amended soils placed on site for the Eljen absorption trenches. I found the stabilized percolation rate to be 4 minutes and 50 seconds per inch. We also performed an as-built survey of the septic system components and house location. I have found all septic system components to be installed according to plan in a workmanlike manner. If you have any questions or would like to discuss this further, please do not hesitate to contact my office. Sincerely, Dennis L. Dickinson, IS, PE `/ dtd sd �- /3—/ 9 / PA / c$A- b�/c -7y.s /' C ir,TOWNsoE,p:iu3EE11,Nios,9BuRy s: 127 fie/re �� fxeu,pw, - $ & 4 f ?Ay- b XxiL l o wl o f 12 7 5// Ave„.,ply f Qk-- L7-7 S,acc G1/$(K eK-e p 46.AI. ,k/hc. 5yik p--t a 660 on, . 4- Pe&ti 7/, pae#v5e haf i6244 deo-e-c=./.`x %S d 6,i a-4 S ►10= r 3 I y lie ROSE MELLON Z% Notary Public,State of Nwv York Warren Co.#01ME6223424 Commission Expires June 14,20 aa— �� � ;