application 12
— - Property Transfer Sewage Disposal Information Form
�- — Date:
ulp
742 Bay Road,Queensbury,NY 12804 /
P:518-761-8256 www.queensbury.net D7)1 7-if Of
(Name of Owner/Applicant)
Re: Onsite Wastewater Treatment System Inspection Information Request for:
(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._P_rior to our inspection,we request
this completed application/a si#e map indicating=theiocation=of-theseptic-comporien sand confirmation the
pre-inspection preparation (ee theiast page of this packet)will be completed—prior-to r 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 15t 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, ICE I
David Hatin, Director l TOVI nFimeN=a:`=t'R
Building and Code Enforcement ! -- ��1 �`�� `�`' �
Town of Queensbury
Property Transfer Packet Revised February 2020
Y � Y
Office Use Only
Permit#: �7�
Town of Qgccnsbun' Fee:
5)61
742 Bay Road,Queensbury,NY 12804
P:518-761-8206 or 518-761-8205 Invoice#: 210 e)
•
www.queensburv.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: /6 z,(fru ig(„r2 a /i/vv)e (u.aeivc-,,ek. i /v v
Tax map number: 314 e s'-
Property owner: Ch D/,4 11ful(C (XF Cu 76 a � � o
fcA .r �r'LiU C'ff Ya?uRpffy
Mailing Address(c/s/z): /6C, Jci&& Gi.vQ / f 72/t Ot cL C a 1zo GU )/ /2(9`S h
Cell#: 6 26' Land Line#: c/eP (5:)-k
Email: C/,4 IA 6 cu.ve/i e�!A Ca I Ce2?
**PLEASE SEE SEPARATE PAGE FOR EXEMPTIONS**
Household Information:
#Bedrooms / #Bathrooms 2 #Kitchens / Jacuzzi tub(s) .1 Garbage grinder 0
Onsite Wastewater Treatment System:
How many systems are on the pyoperty?
Year system(s)ins led: T Size of Septic Tank /Cro o GAL
Type of Absorption System:_ Dip.,4a..p 7 7
Are all system components wholly within the property boundaries? [ es 0 No [, c 3 Tit.7
Are system plans available? 0 Yes ®"No D
ll// AUG 2 5 L12:J
Does the system(s)serve multiple properties? 0 Yes L["No
If yes,describe TOWN OF OlSE�..'' SBURY
BU16 DING a CODES_
Maintenance:
Service agreement? 0 Yes No If yes,vendor name
/1 /AD
o &r SPv/1slrc0 JDate of last inspection�N/A ❑ Date tank last pumped P1U�Cr.
Frequency of pumping 7 N/A ❑ Y//8/.2a2.0 an _Ping M, 774
p Pifrn* fepi<c 7a fpgr/rL , 1_,J-9.
74.2 V elide 776 afG--[.t(}-j-z virpac Z`i u,L, .
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 V No
• Direct surface discharge(s)? Yes No
Back-up of toilets? Yes V/No
• Back-up of any other fixtures?(e.g. slow drains) Yes V No
• Seasonal ponding or breakout of leach field? Yes V 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 (A/sz HA-4 77414--7 9YuAt (Uiv !� 1.0o
• Have th ifil iepresentat Ve present at the site; i t f 14 ee/3.0 774a SUIT:0 ma-e-T
• 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
D i
Please print name: pi a i ro ci Inel
Affiliation: owner agent h i a l ') &__-
Signature: , Q.0 f) figOh_bit' s r Date: '2'( '2 o
Prior to scheduling with the Town of Oueensburv,von 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. Exposeifiletand 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