application . . Office Use Only
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Permit tit -CT— tic?-8 2..CZY1
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Fee: 1250
742 Bay Road,Queensbury,NY 12804
P:518-761-8206 or 518-761-8205 Invoice#: 110 N3
www.aueensbury.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: -2-,C1 5-. 2 Ter-TE RatAE. 9. L.-
Tax map number: 2-S 2..-0 7 -I 13
Property owner: _ Sr—e? racc0
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Mailing Address (c/s/z):
Cell it: ctil 5-tot' (90157- Land Line#:
Email: S S 1>i 0 1--IME,
Household Information:
\\J
it Bedrooms I_ #Bathrooms 1 #Kitchens I JUN 1 0 2019
Onsite Wastewater Treatment System:
How many systems are on the property? 0 B11 VuN1 LOD NOGU 8,E EASDBEUsR Y
Year system(s) installed: Tank Size of Septic Tank
_Type of Absorption System: _
Are all system components wholly within the property boundaries? 0 Yes 0 No
Are system plans available? 0 Yes No
Does the system(s) serve multiple properties? 0 Yes 0 No
If yes, describe
Maintenance:
Service agreement? 0 Yes 0 No If yes,vendor name
Date of last inspection N/A CI Date tank last pumped N/A 0
Frequency of pumping N/A
Property Transfer Packet Revised March 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 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.
I agree to be responsible for inspection fee payment.
Signature of property owner or authorized agent
Please print name: S It S c —�
Affiliation: K e ner agent Ito ga0e_ a`.c) • 1 ik36 otO 9 P
iatil
Signature: / Date: (m 3 20
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 ofseptic tank; and/or pump station, exposed-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
June 3,2019
To: Town of Queensbury
Wastewater Department
Attention: David Hatin
742 Bay Road
Queensbury, NY 12804
From: Scott Sbrocco
423 Wyckoff Ave •
Ramsey, NJ 07446
RE: Application..for Exemption on Purchase of Property
at 2952 State Route 9L,Tax Map#239.20-1-13
David,
As per our phone conversation find attached the following:
1. Notarized Affidavit
2. Property Transfer Sewage Disposal Application
3. Check for$2,250
Please let me know if you need anything else to provide Carol and myself with the exemption required
to purchase the above property without a septic inspection. Our closing date is schedule for Friday
June 28,2019.
Sincerely,
Scott Sbrocco
(917) 560-6015
ssbrocco@optonline.net
June 3, 2019
To: Town of Queensbury
Wastewater Department
742 Bay Road
Queensbury, NY 12804
From: Scott Sbrocco
423 Wyckoff Ave
Ramsey, NJ 07446
RE: Affidavit to Install Compliant Septic System
at 2952 State Route 9L,Tax Map#239.20-1-13
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STATE OF NEW YORK)
)SS..
COUNTY OF QUEENS)
Scott Sbrocco, being duly sworn, deposes and says that:
1. My wife, Carol Sbrocco, and I are purchasing the above referenced property from
Daniel &Suzanne Lombardi and Michael Novak.
2. The sellers do not wish to have the current septic system inspected pursuant to the
Town of Queensbury Local Law Chapter 137.
3. My wife and I agree to inspect or repair the septic system within 6 months of the
transfer of title of said property into my name or June 1st of the current, or following calendar year
(whichever comes first), or the installation of a holding tank if a code compliant septic system cannot be
reasonably installed.
Scott Sbrocco
•
Sworn to before me this cam"
day of June, 2019.
otary Public
Affix Stamp or Seal SUSAN R. PHILLIPS
NOTARY PUBLIC-STATE OF NEW YORK
No.01 PH6219119
Qualified in Queens County
My Commission Expires 03-22-2022