application Office Use Only
Permit#: . fl 'A- .20'20
Town of Qircen sbgn
Fee: . .
742 Bay Road,Queensbury,NY 12804
P:518-761-8206 or 518-761-8205 Invoice#:
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)
Propertyaddress: ��
Tax map number . 3 0 63.1.6 . .. 1 (O S_
Property owner Qom- , .
Mailing Address(c/s/z): 5r .
Cell#: r (cr `'1 Land Line#:
Email.: C CkLi. itiSO CC.01
**PLEASE SEE SEPARATE PAGE FOR EXEMPTIONS**
Household Information: i
#Bedrooms 3 #Bathrooms I R #Kitchens . I Jacuzzi tubs) 0 Garbage grinder D
Onsite Wastewater Treatment System:.
How many systems are on the property?
Year system(s)installed: Tanks t Size:of Septic Tank:\t0ID
Type of Absorption System: . E C IE 0 V E
Are all system components wholly within.the property boundaries? )Yes 0 No jDJ
Are system plans available? 0 Yes 0 No SEP 3 0 2020 1)
Does the system(s).serve multiple properties? 0 Yes No
TOWN OF QUEENSBURY
If yes,describe BUILDING & CODES
Maintenance:
Service agreement? 0.Yes.., No If yes,vendor name _ ..
Date of last inspection eN/A 0 Date tank last pumped d.110 N/A C 'o
Frequency of pumping N/A 0
Property Transfer Packet Revised October 2019
List known repairs/replacements, with dates:
Date Type of Repair/Replacement
Operation'.
• System problems? _ Yes No
• Sewage odors?. Ye
s No
• Direct surface discharge(s)? Yes >c 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 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: C,a(),R C? 3-- Az
Affiliation: X owner agent .:
Signature: C Date:
Prior to scheduling with the Town of Oueensbury, 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
(
1
Property Transfer_Sewage Disposal Information Form
' . \
- = - Date: "I 9`c Q< t
;Town•�of Queensbwy
742 Bay Road,Queensbury;NY;12804
P:518-761-8256 : •www.queensbury:net
(Name of 0 /Applicant). '
Re: Onsite Wastewater Treatment System Inspection Information:Request for .
5 rl" " K, c3,-,,,,--4...., ,,. Cam' G,,L,J,,,,, ,
: . .
• (Site Address)
Thank you for req es=an inspection for the onsite wastewater treatment system.(OWTS) located:on the
propertyreferenced"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 fees) and documentation,prior to:scheduling an inspection."
_ _ Please note the Town of Queensbury's"fee for this service:i $250 a 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 andpayment totalin $2250.($2000 refundable-de osit 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; D �� .�
, i � 7 :SEP3
IED
0 2020
David Hatin, Director
Building and Code Enforcement TOE"OE QDEENSBURY g BUILDING& CODES
Town of Queensbury
Property Transfer Packet Revised February 2020