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application Property Transfer Sewage Disposal Information Form Date: q pq e l3 23 Town of Queensbury 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.queensbury.net �) ac- thr . 13. (,0 heel e-r" (Name df Owner/Applicant) Re: Onsite Wastewater Treatment System Inspection Information Request for: 34 Gunn Lane , C�veg-e,shvin ) M `/- (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. Fh as ate ' e (0 brr y fee or 41 i ' nlitV.F.11 I .es m J oa Sir°o,,o ',o. Tel e Jmg I inspection. ire( "774'1101IGU.4 hour no r Ica ,i i T.°)rt(oI� �a>�otUii�nJ: tanL h141 =° 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. Sincerely, BvEn SEP 2 4 2020 David Hatin, Director Building and Code Enforcement TOg�ILp�G EEC CO©ES Town of Queensbury Property Transfer Packet Revised February 2020 4 (f: Office Use Only �,g� Permit#: ? —O5O6 .2O2o _ ZTown of Quecnsbun' Fee: 742 Bay Road,Queensbury,NY 12804 II P:518-761-8206 or 518-761-8205 Invoice#: �� b www.queensbury.net SEWAGE DISPOSAL SYSTEM INSPECTION INFORMATION Individual Residential Wastewater Treatment System Property and Owner Information: Lane attach property survey or tax parcel map) Property address: 34 G V n n Lane , C ) IA ee ns 2`7 burl `v Y. i z so 4 Tax map number: 2. • J 7" 1 " `7 9 `J Property owner: J G Covue line 1j . Ltd i e efe r Mailing Address (c/s/z): 5 A'n'1 e Cell#: qO7-7 O --a 1 I, ) Land Line#: Email: cJUl(J()€ +rO frl/heefP, J ()lat I , C U tr-1 **PLEASE SEE SEPARATE PAGE FOR EXEMPTIONS** Household Information: #Bedrooms 3 #Bathrooms 3 #Kitchens , Jacuzzi tub(s) 0 Garbage grinder d Onsite Wastewater Treatment System: How many systems are on the property? Year system(s) installed: Tank t 1 Size of Septic Tank 11LS0 w 14''h It 00 b 9G I II') ,mir Type of Absorption System: Pre S b/ G ysas M P Are all system components wholly within the property boundaries? Eyes ❑ No Are system plans available? ['Yes El No OIL g it, T 0 G Does the system(s) serve multiple properties? El Yes CNo I1 If yes, describe I ' U Maintenance:- SEP 2 4 2020 Service agreement? ❑ Yes El No If yes,vendor name TOWN OF QUEENSBURY Date of last inspection v/is N/A ❑ Date tank last pumped N/A C BUILDING&CODES Frequency of pumping N/A ❑ Property Transfer Packet Revised October 2019 ti v List known repairs/replacements, with dates: Date Type of Repair/Replacement None. 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 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 tA) Please print name: A--1 'e b. , In t'e1 kr Affiliation: ✓ owner agent S°= o Date: ,31 Z/.-2. 0 l'!An r o -1;e_dillin ,vith h io,n o, ftreensiof iry, mon 1 daU: : 1 Srhedule=a=sewage i a-ulerrto4be-on-site�to-pumplank while-inspector is,on_s ste. Hauler,should-.arr..ive=30=45,-minutesrafter=scheduled time,with,the Town,ofzQucensbnry's;, Code-Enforcement=Officer:•' 2. Exposes.inlet_ancLoutlet=of-septic�tank,and/or=pu np,station exposezd-box,-expose, anyyseepage-pit c-over-s.- 3. Excavate test hole in leach field if there is no. d-box. Property Transfer Packet Revised October 2019