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PT-0581-2020 S Property Transfer Sewage Disposal Information Form Date: Tow"OQUweens ury 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.gueensbury.net (Name of owner/Applicant) Re: Onsite Wastewater Treatment System Inspection I o anon Request for: (Site Address) Thank you for requesting ap 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 (seethe last page of this packet) will be completed prior to our arrival. Enclosed .is a Sgptic System Inspection information form, which must be completed, signed and returned to this oi�C with the appropriate fee(s) and documentation, prior to scheduling an inspection. Please note the Town of Queensbury's fee for this service is$250. 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 11t 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 oWper 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,: -` - (00ods SEP 2 3 2020 David Hatin, Director TOWN OF QUEENSBURY Building and Code Enforcement BUILDING&CODES Town of Queensbury Property Transfer Packet Revised February 2020 Office Use Only Permit#:. PT - Ot*\ - 2O7A iT .Wt.= Fee: 742 Bay Road,Queensbury,NY 12804 P:518-761-8206 or 51S-761-8205 Invoice www.ciueensbury.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: hcG4, Sh �,{ Tax map number. 31 Lp. 1 -9- Property owner: Li n dQ Len 'n) Mailihi ANddress (c/s/z): Cell#: � �� 5TJ SS Land Line#: Email: rl y�r - U o? Q I ck4 do rr,. "PLEASE SEE SEPARATE PAGE FOR EXEMPTIONS" Household Information: #Bedrooms #Bathrooms #Kitchens Jacuzzi tub(s)� Garbage grinder �l Onsite Wastewater Treatment System: How many systems are on the property? j Year system(s) installed: Tank Size of:Septic Tank 1000g0a16n Type of Absorption System: Are•all system components wholly within the property boundaries? Yes ❑ No 'Are system plans available? ❑ Yes ❑ No Does the system(s) serve multiple properties? ❑`Yes No If yes, describe SEP 3 2020 Maintenance: 13 Service agreement? ❑ Yes TOBUI DIN&CODES N OF Y gr �9,No If yes,vendor name Date of last inspection N/A El"Date tank last pumped 6 N/A ❑ Frequency of pumping /A ❑ Property Transfer Packet Revised October 2019 List known repairs/replacements, with dates: Date Type of Repair/Replacement Operation: + System problems? Yes t/ 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 —7-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 seppage 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. tWthelbes't of my knowledge, the information provided above is accurate and Lacknowledge 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: Q le A)�^J I Affiliation: owner - agent Signature: Date: (, J Prior to schedul4e with own of ueensbu -you MUST: 1. Schedule a sewage hauler to be on site to pump tank while inspector is-on site. Hauler should arrive 30745 minutes after scheduled time with the Town of Queensbury's Code Enforcement Officer. 2. Exppse 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-bog. Property Transfer Packet Revised October-2019 EXEMPTION CONDITION OPTIONS Due to one of the.conditions listed below, I am requesting an exemption from the Septic Inspection Upon Property Transfer by the Town of Queensbury: ❑ The property to be sold or transferred will not be inhabited, and the new owner plans to demolish the existing structure. In.order to qualify for the exemption, a notarized affidavit must be submitted to the Building and Codes Enforcement Office stating that the dwelling will not be inhabited and that it will be demolished with no immediate plans to rebuild or the dwelling will not be inhabited,it will be demolished and rebuilt, in which case the affidavit shall be accompanied by a site plan, including adequate detail to demonstrate a lawful OWTS,together with a check payable to the Town of Queensbury in the amount of$2,000. Such funds will be held in a non-interest-bearing escrow account and will be released, in the former case, upon issuance of a demolition permit and, in the latter case, .upon issuance of a certificate of compliance from the Building and Codes Enforcement Office. If the Property Transfer'inspection is not completed within that 6 (six) month timeframe, the $2000 will be forfeited. ❑ An OWTS inspection was not able to be completed prior to the conveyance of real property due to .... ,,inclement.weather.-In order to qualify for the exemption, a notarized affidavit from the new,property owner to complete the requisite OWTS inspection within six months of the date of the conveyance of real property, or June 1,whichever comes first,must be filed with the Building and Codes Enforcement Office. A check payable to the Town of Queensbury in the,amount of$2,000 will be held in a non- interest-bearing escrow account and shall be released upon the completion of a satisfactory OWTS inspection from the Building and Codes Enforcement Office. If the Property Transfer. . inspection is not completed within that 6 (six) month or June V timeframe; the. $2000 will be forfeited. ❑ The property to be'sold or transferred contains.an existing OWTS that does not comply with the provisions of this article, and the prospective purchasers and/or the Seller wish to forgo an inspection In of installing an approved OWTS within six months of the transfer of property. In order to qualify for the exemption; a notarized affidavit must be.submitted to the Building and Codes Enforcement Office stating that.the existing OWTS will be,replaced within six months from.transfer bf property.The affidavit must be accompanied by a site plan, including adequate detail to demonstrate that the replacement OWTS will comply with this article, together with a check payable to the Town of Queensbury in the amount of$2,000. Such funds will be held in a non-interest-bearing escrow account and will be released upon issuance of a certificate of compliance from the Building and Codes Enforcement Office. If the Property Transfer inspection is not completed within that 6 (six) month timeframe, the $2000 will be forfeited. Property Transfer Packet Revised October 2019 ❑ During the OWTS inspection, a failure of the septic system was determined. Due to winter and frozen conditions, the repair to an existing OWTS could not occur or a,new OWTS could not be installed before the conveyance of real property.,In order to qualify for the exemption, a notarized affidavit from the new property owner to,complete the installation or repair of the septic system within six months from the date of the conveyance of real property, or June 1, whichever comes first, must be filed with the Building and Codes Enforcement Office. A check payable to the Town of Queensbury in the amount of$2,000 will be held in a non-interest-bearing escrow account and shall be released upon the completion of'the repair or installation of a new septic system and a satisfactory OWTS inspection from the Building and Codes Enforcement Office. If the Property Transfer inspection is'not completed within.that 6 (six) month or June 1st timeframe, the $2000 will be forfeited. ❑l There is a record of a septic system inspection upon property transfer permit and inspection completed and passed within the last three years. Please provide a copy of this record. PLEASE READ NOTICE THOROUGHLY: Failure to complete the inspection, obtain the permit or complete.all repairs/installations identified in the preceding subsections of this section within the time provided or any subsequent deadline established by the Building and Codes Enforcement Office will result in forfeiture of the moneys held in escrow, and the Town may use such.funds toward abating the conditions caused by each such.violation of this article. Inspections trust take place within one (1) year of submission of a comp leted'application. Inspections scheduled to take place after the one year period will be subject to submission of a r+ newal,application and payment of the renewal fee based on the current fee schedule. I have read and understand the above notice regarding the expectations and possible forfeiture of moi eys submitted to the Town of Queensbury for an exemption request. Seller: -Print Name: ,v,d ,q- ,u �?_Aj r Date: ,•� Sign lvatne: 22 �-- '`--' � Date: �2 6 Buyer: l .Print Natrie: C4A' Date: • 2 2�� Sign Name: Date: • old Property Transfer Packet Rcviscd October 2019 r:.zta SEWAGE DISPOSAL SYSTEM EXEMPTION COMPLIANCE LETTER Town of Queensbury 742 Bay Road,Queensbury,NY 12804 P:518-161-8256 www.gueensbury.net Date: 7 October 2020 To: Nicole &Joseph Pickering (Purchaser) Re: System Inspection Site Report for: 3 Palmer.Dr, Queensbury NY 12804 (Site Address) The purchaser of the above-referenced parcel has submitted to the Town of Queensbury an exemption. request which includes a notarized letter stating the existing septic system will be.repaired on or before 6(six) months from 14 October 2020. The purchaser and seller, Linda Lentini,'have submitted a,waiver deposit of$2000, and the purchaser has also paid the $250 inspection fee. If, however,the Septic Inspection Upon Property'Transfer has not occurred or a replacement system has not been installed within 6 months of the date of Property Transfer,the $2000 waiver deposit will be forfeited. Sincerely, 4 David Hatin, Director Building& Code Enforcement Town of Queensbury Building&Code Enforcement September 2019 Jamie � � 44 "c Lf eodv- on 0 r- rn o n,4�hs miry, Vo4o I , 1 CANDY A CAPPE O' ' t Notary Public, State of New York Registration No.01 CA6222132 Qualified in Washington County Commission Expires May 17,20 ■�f��ir■■ti■■i■■■tirsl�l�iti■<rrrrr■■��l�ri■i■tr■■ :: �' ■■r,::i■rrtriii■■■■■■i�iiF.'.,►}!�■■r■ii■itlG'dn■ii■■■■ �. • �rar�r■■i■err■■m■■rr■al��rt■r�■i■■�■��■r■■■�■rrs■ �i�r�:�t��r� �a■N■■r■r�r��r►a,nr��ar■�r■s■■■■ r��rr■��1�.�:��■■�■■■rn■� .r�ar■■rrrrrrrrrr■■■■■r�r■ rrr�rr■n��= r■nr■■�r�;��r■��r■rr■■�■■r■■�inri��:�� - r�+rrar■rr�■�r�r��{�■rr�n�rr■r�r■i�■i��-�r - ■ .':�5r��' ,rirri�■■■r�i��{!/i ■ri � l�r1■■. lt ■rir� ■y rr r�rr■■{�r■■ENN■■■�tr� ■■■w�:ar �■r r�■rr�r■ • • r{ilod�,E ��■r■rr �■■� ,�■■u��nrr{�►��rrrrr��■riri�� uer��■rrr■■ ■ � �■F��■■■■��:rr■��rrrr■�■■�rr��i ■C.i/��rr■r■ �■■ _r■■�r�rr■r■■rrr�rrrrr!/rri■■■i/ �r � � :�`■■rr 'r■■�111■■■r■■ir■rrr{�■rirtii■ ■��M�r�f ■r■■■r■■■�r■■■rrt�rsrr�r�■r■■r�l�rrrr��n • ■1�rii7■j■■r■■r�■■ir■■■iri��■rrri��■V�r��il� ■11��-��■iir■■i■rl/!�.>'�t■l�i�.�i�r•rw■ii�siiitr�'�rr�1 . ■r�°a�-I:��r■rrrr■■r�r�r■■■■r■�r■r�■rrr■��rrr■■�rrr . . � ■��■ire■rrr■rrr■� _.r..r■�nrr{�■rr■r!�■■■�i■■■rrr■rr■ ■�■■■�rr��r�+■�:■r� r�r■��■r■■■■■■■r!�■��-�i■■rr�rrrr r�■��■rrr�ir �� -�lrrrrrrE��■{n■r■i■rr■��nrrrrrr■■ i�i1�"� ■{r��{��■rrrrrr�lrr{■■rr■r■rrri�rrrrrrrrrr �rrr�r��r!�r� �r�■rrrrr■rrrr�■■■■rrrrr��rr■�rrr■rrr ■sr�■�■■r�■�■irrrr■■rrr■■■■■r■■■r■�rrr■irrrrrr L Dennis L. Dickinson, LS/PE DICKINSON (TEL) 5 f 8-668-4676 Devm T. Dickinson dldickin5on78@gmad.com ASSOCIATES SURVEYORS• ENGINEERS• LAND CONSULTANT5 Location: 30 Stone Schoolhouse Road Mail: P.O. Box 388, Lake George, New York 12845 30 June 2021 David Hatin, Building Codes Town of Queensbury 742 Bay Road Queensbury,New York 12804 RE: Pickering—Wastewater Treatment Inspection Dear Dave: I have inspected the septic system components located at the above referenced parcel on 25 June 2021 and 30 June 2021. 1 have found that the drain line,septic tank,pump tank,force main and stone bed have been installed according to plans in a workmanlike manner. I have attached herewith,an as-built survey showing the approximate location of the installed components. If you have any questions or would like to discuss this further, please do not hesitate to contact our office. Sincerely, nuKO Dennis L. Dickinson, PE Email:dldickinson78@gmail.com 04/20/2021 13:42 5186265634 ALBANY PAGE 02/02 April 20,2021 Town Board of Queensbury NY ATTN:'town Supervisor Strough ' Bldg Permit#:SEP-0054-2021 OU�E�SOFfI ' Project:Septic Altercation Location:3 Palmer Drive . Applicant Name: Pickering Please accept this letter as we are requesting a time extension to get the septic project to get done,so we do not lose or forfeit our 2000.00 deposit check. At this time,it will not be able to be done by April 30"by Charles Friedman Excavating,who we have chosen. Due to inclement weather,his jobs have gotten pushed back by a few days and our tentative week of April 261h,2021 has since gotten pushed back as well. Chuck himself has asked us to ask for more time to get this done as he has said to us that he will not be able to complete this at this time now by April 301h,2021 due to weather pushing back his other jobs and not enough guys,as he is shorthanded right now as well and does not want to rush and get our job done,or others. Chuck states that he will have the job done by the end of May 2021 for us. Thank You, Nicole&Joseph Pickering Any questions please contact us, Thank You (518)932-5696-Joe Pickering (518)932-2101-Nicole Pickering (518)361-1748 Chuck Friedman F . s