PT-0368-2021 r•
Office Use.O,nhy...�. 2
Permit#: 2e
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'Town of CQuccnsbun• Fee:
742 Bay Road;Queensbury;NY 12804
P:518-761-8206 or 518-761-8205 Invoice#:. .
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: 3 5 6 (-6 F . L4L& �D fob 9 i aN5
Tax map number:' celo 9'
Property owner: VOA � �0�no 5
Mailing Address (c/s/z):?�S `�t tc1 ' d Lo��C2 Cxo.�c�e
Cell #`1 a3-1$ri 3T)1 Land Line#:
Email: Va�T�yx4f-i01 0$@ �mA� ►/�
Applicant (if different than above):
Mailing Address (c/s/z): .
Cell#: Land Li he#:
Email:
❑ Proposed Owner ❑ Realtor ❑ Attorney ❑ Other(explain: )
Septic Contractor:
Mailing Address (c/s/z):
Cell#: Landr'Line
Email:
Reason for Inspection Request,
❑On the market ❑ Future listing Sale Pending ❑Deed Transfer ❑Other:
Properly Transfer Packet Revised April 2021
HOUSEHOLD INFORMATION
**PLEASE SEE SEPARATE PAGE FOR EXEMPTIONS**
#Bedrooms 3 # Bathrooms #Kitchens..�L Jacuzzi tub(s)�o Garbage grinder 0
Onsite Wastewater Treatment System:
How many systems are 'on the property?
Yearsystem(s) in stalled:,TankQ_92q.bSize of Septic Tank
Type of Absorption;System:
Are all system components wholly within the property boundaries? Y es ❑ No
Are.system,plans available? [ Yes ❑ No
Does the system(s) serve multiple properties? ❑ Yes [ /No
If yes, describe
Maintenance:
Service agreement? ❑ Yes [I No; If yes, business' name SRC%I w S&r-c suvict
Date-of-last inspectio M ` Oi(p N/A❑ Date tanklast pumped 5 al I CA N/A❑
Frequency of pumping N/A ❑
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. p'.No
Back-up of any other fixtures? (e.g. slow drains) ❑Yes allo
Seasonal ponding or breakout of leach field? ❑ Yes EIrNo
Property Transfer Packet Revised April 2021
Inspector's No.:
COMMONWEALTH ELECTRICAL INSPECTION SERVICE, INC.
(Consulting and Fire Inspection Services)
(Incorporated in the states of New York, Pennsylvania, and West Virginia)
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Desiring Certificate of Approval,application is made for inspection of electrical installation in the premises described below. On
demand,applicant agrees to pay for inspection service in accord with schedule of charges.
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Owner: (—�(5i,, ;.�rz r7-S
Type Building:Dwelling Other(please specify):
Job Location �" %�f/2%t I�:I� City: ;j)- pa" yA' C.t% State: ✓•�
County: J. Permit From: 'Permit# > N ! r
Swimming Pool: Inground: Aboveground: Bonding Date:
{ Work-New Additional Bldg.- New Old Ready for Inspection f: �' �' ;
Applicants Signature: b<r. f�'' '( S/;,iv t J r' a` -s License#:
Please Print Name: Phone#: 76 3- .7. i � ,
Applicants Address: Name of Utility: ti ;r tjZ_
City: Office To Be
f ie � Za, t 1 r
0�`o ro, State: --( Zip:, _�'(�; Notified: Job#:
SPACE BELOW FOR USE OF INSPECTORS ONLY
Switches Water Heater Service Equipment Other list below
Receptacles Paddle FarAight Control Service Equipment
GFCI Rece t Paddle Fan Panel
AMP Rece t Paddle Fan/Light Dryer Rec
Lights Vent Fan Washer Rec
Lights I Air Conditioner I Dishwasher Rec
Smoke Detectors AFCI Breaker Microwave Rec
Smoke/CO Detectors GFCI Breaker Garbage Disp Rec
AFCIIGFCI Breakers Refrigerator Receptacle
Additional apparatus for certificate:(Not listed above) Inspector Job Notes:
r
Installed By(if other than applicant):
OFFICE USE ONLY
Date Received: Extra trip dates inspection Fee$
Service Date; 1 CASH t'
R.W.Date: 2 Check No.
Certificate No: Final Date: !r I(. r+ 3 Invoice
Certificate Needed? 4 CC
Date Sent: Inspector sign in
Y.11 es_Dup_ next space
Please print name inspector' �,i it S ."I 11'n r,
Original Progress Final
THIS APPLICATION EXPIRES ONE YEAR FROM DATE MAKE ALL FEES PAYABLE TO C.E.I.S.INC. ;
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