PT-0105-2021 1,
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Property Transfer Sewage Disposal Information Form
1
,�Date: 21
Town of Queensbury
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.gueensbury.net
60
(Name of Owner/Applicant)
Re: Onsite Wastewater Treatment System Inspection Information Request for:
(Site Address for Inspection)-
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. Priorto 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.
Please note the Town of Queensbury's fee for this service.is$275. 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 1st of the current, or following year (whichever comes first), a map locating the septic
system and payment totaling$2275 ($2000 refundable deposit plus$275 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 E C E 0 V E
(:2)j 44 t. I MAR 1 9 2021 11
David Hatin, Director TOWN OF QUEENSBURY
BUILDING&CODES
Building and Code Enforcement
Town of Queensbury
Property Transfer Packet Revised December 2020
r Office Use Only
Permit#•
Torn of Queens bury Fee: 2-
742 Bay Road,Queensbury,NY 12804 2.A LL
P:518-761-8206 or 518-761-8205 Invoice#: eI_r_x K7
www.gueensbury.net
SEWAGE DISPOSAL SYSTEM INSPECTION INFORMATION
Individual Residential Wastewater Treatment System
CONTACT INFORMATION (please print legibly or type and include an email address)
Property and Owner Information: (Please attach property survey or tax parcel map)
Property address for inspection: `2 64 CAFE i;z�
Tax map number: 5`�- 9+00 209. i 3 —J "4
Property owner: � � )
Mailing Address (c/s/z): -26 :a i,r�ZAIl RD LAKE ai=01�65 &a 12 45
Cell#: �U&- 796 • bQ9 Land Line#: 50 7 �5
.Email: b3rel{, f fmo l f - com
Applicant(if different than above):
Mailing Address(c/s/z): E c 1E nu V
Cell#: Land Line#: MAR 11 2021
Email:
OWN OF QUEENSBURY
❑ Proposed Owner ❑ Realtor ❑Attorney ❑ Other: BUILDING&CODES
Septic Contractor: Ac T) 6 I,y '5 F i G
Mailing Address(c/s/z): 57 �Atz,4 A AyE boa &t—ES5 F4,1_/_ 5
Cell#: Land Line#: ell
Q 5
.Email:
Reason for Inspection Request:
❑ On the market ❑ Future listing ale Pending ❑ Deed Transfer ❑ Other:
Property Transfer Packet Revised January 2021
HOUSEHOLD INFORMATION
"PLEASE SEE SEPARATE PAGE FOR EXEMPTIONS"
# Bedrooms # Bathrooms # Kitchens `2 Jacuz ub(s) Garba rinder
Onsite Wastewater Treatment System:
How many systems are on the property?
Year system(s) installed: Tanka9103 Size of Septic Tank l DOD <57AL
Type of Absorption System: �_EAC41 fl&-LD
Are all system components wholly within the property boundaries? .Wes ❑ No
Are system plans available? Xyes .' .No
Does the system(s) serve multiple properties? ❑ Yes No
If yes, describe
Maintenance:
Service agreement? ❑ Yes _1<No; If yes, business' name
Date of last inspection 0J N/A ❑ Date tank last pumped 17 ? N/A ❑
Frequency of pumping N/A)<
List known repairs/replacements, with dates:
Date Type of Repair/Replacement
(AC= T--Igom �46ysE -ro TAKL V,
Operation:
System problems? ❑Yes , CNO
Sewage odors? ❑ Yes' `XNo
Direct surface discharge(s)? ❑ Yes XNO
Back-up of toilets? ❑ Yes PeNo
Back-up of any other fixtures? (e.g. slow drains) ❑ Yes Flo
Seasonal ponding or breakout of leach field? ❑ Yes ;�Ao
Property Transfer Packet Revised January 2021
Statement of Acceptance of Conditions:
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:
Affiliation: Aowner Dagent Elother:
Please print name:
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 January 2021
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289.13-1-44 PT 0105-2021 vN
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254 Glen Lake Rd
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