PT-0259-2021 Office Use Only
i
Permit#: i
rohm ckfc�ZK--'y Fee:_$ Z
742 Bay Road,Queensbury,NY 12804
P:518-761-8206 or 518-761-8205 Invoice#: l(xr,.iv
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: �—Lyv
L `ti6
Tax map number: ;tqq, It)
Property owner: ICfo2 CLLAdols ALL&K
Mailing Address (c/s/z): -4 slo N C- Y-/%JE bu A y � /V y 1 2-6 L(
aoua
Cell #: 5i8-352-c(157L�-L-i.ae-#- 5-IT-a,-z2-9332--
Email: �Wm t jj P-R
Applicant (if different than above):
Mailing Address (c/s/z):
Cell#: Land Line#:
Email:
❑ Proposed Owner ❑ Realtor ❑ Attorney ❑ Other (explain: )
Septic Contractor: QS 5�f t�C- ` 1Jr'l N
Mailing Address (c/s/z): LoWC-R W,+ARErV -51,
Cell #:51 K-- 361-0 L5and Line#: 5` 9 - 7�? -$199{
Email:_Cbezz '' 7y-sse.p c , C'oM
Reason for Inspection Request:
❑ On the market ❑ Future listing Sale Pending ❑ Deed Transfer ❑Other:
Property Transfer Packet Revised April 2021
Property Transfer Sewage Disposal Information Form
Date:
Town of Queensbury
742 Bay Road,Queensbury,NY 12804 , t 11,r
P:518-761-8256 www.gueensbury.net
A� ' f,
icf,R �l14c1o� 1�oce�l�rs LLc� Tom
(Name of Owner/Applicant) ��1�0fi1 A
infC; J.
Re: Onsite Wastewater Treatment System Inspection Information Request for:
-�9 �V Y LvaF ) , �9 KE �EOc��C� IV IV 1.29�7
(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,
)j/I
David Hatin, Director
Building and Code Enforcement
Town of Queensbury
Property Transfer Packet Revised April 2021
HOUSEHOLD INFORMATION
"PLEASE SEE SEPARATE PAGE FOR EXEMPTIONS"
# Bedrooms # Bathrooms oZ- # Kitchens irZ Jacuzzi tub(s) � Garbage grinder
Onsite Wastewater Treatment System:
How many systems are on the property?
Year system(s) installed: Tank Size of Septic Tank
Type of Absorption System:
Are all system components wholly within the property boundaries? [XYes ❑ No
Are system plans available? ❑ Yes ❑ No P,4-K1-LA-L
Does the system(s) serve multiple properties? ❑ Yes No
If yes, describe
Maintenance:
Service agreement? ❑ Yes No; If yes, business' name
Date of last inspection N/A ❑ Date tank last pumped 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 g No
. Back-up of toilets? ❑Yes �CNo
. Back-up of any other fixtures? (e.g. slow drains) ❑Yes M No
. Seasonal ponding or breakout of leach field? ❑ Yes J�No
Property Transfer Packet Revised April 2021
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:
Affiliation: �owner ❑ agent ❑other:
Please print name: V1 cTaz CELA-t o �' b aa0 Mc l(e P—
aSignature: Z GT: Ge 672 i A- 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 April 2021
Doug Miller
4 Stone Pine Lane
Queensbury, NY 12804 ,
June 1, 2021
Town of Queensbury
Buildings and Codes
742 Bay Road
Queensbury, NY 12804
To Whom it may concern:
This letter is to confirm that the current owners and sellers of 7, 9 and 11 Ivy Loop Rd,
Queensbury, NY(parcel numbers 289.10-1-24 and 289.10-1-26) will have the installation of the
two septic systems completed, as designed and approved under Town of Queensbury Building
Permit numbers SEP-0402-2021 and SEP-0403-2021.
Furthermore,these installations will be completed within six months of the closing date of the
sale of the property, which is currently scheduled for Friday, June 4, 2021.
Si c rely, /
l ,
D ugVliller
STATE OF NEW YORK )
ss..
COUNTY OF WARREN )
On the day of June, in the year 2021, before me, the undersigned, a Notary Public in and for said
state, personally appeared Doug Miller, personally known to me or proved to me on the basis of
satisfactory evidence to be the individual whose name is subscribed to the within instrument and
acknowledged to me that he executed the same in his capacity, and that by his signature on the
instrument,the individual,or person upon behalf of which the individual acted, executed the instrument.
iNiARIA Fla GAGLIAROI ,
,Notary Public,State of New York / � L
No.01 GA6061460 � � L` fci
Qualified in Warren County �2 Notary Public
Cornmissioh Expires July l6; �.
aL`=01 - 7AZ1
SEWAGE DISPOSAL SYSTEM EXEMPTION COMPLIANCE LETTER
Town of Queensbury
742 Bay Road,Queensbury,NY 12804
P:518-161-8256 www.gueensbury.net
Date: 1 June 2021
To: Douglas Miller
(Requester)
Re: System Inspection Site Report for:
7 &9 Ivy Loop Rd, Lake George, NY 12845
(Site Address)
The seller 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 replaced within 6 months from of
the date of the initial inspection of 4/28/2021.
The seller has submitted a waiver deposit of$2000. The septic installation and inspections must be completed
and passed within 6 months of the initial inspection of 4/28/2021 to avoid a violation. .
Sincerely,
David Hatin, Director
Building& Code Enforcement
Town of Queensbury
Building&Code Enforcement September 2019
RUCINSKI HALL ARCHITECTURE J'
Ronald Richard Rucinski ``�� •
Ethan Peter Hallg'�
G�
134 Dix Avenue:
Glens Falls NY 12801
Voice 518 741 0268
Fax 518 741 0274
Email ephall@nycap.rr.com
11 Ivy Loop.
Camp system
19 July 2021
Town of Queensbury Building Department.
742 Bay Road
Queensbury :NY 12804
Re: .Installation.of Replacement sewage disposal.system
At the above referenced project location this office observed the installation of the new septic tank,
effluent pump chamber, distribution box, and gravity infiltration laterals (rated-H-20 for traffic area)
prior to backfill. This installation is acceptable to this office. If there are any questions please .
contact our office to dis us
Regards,
r:'/`J JAY n' •,J���^ .t �`'� .. '
Ethan er Hall.a..d
Architect
oc
Y ,..
AS BUILT
DECRYED
TOWN OF QUEENSBURY
JUL 19 ���
BUILDING ODD EPTa Towle®F o�,EE" 31311.,
BUILDING& Conc,
Reviewed B�:
Date: /� ��