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PT-0282-2021 A, l Property Transfer Sewage Disposal Information Form Date: Town of Queensbury 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.gueensbury.net (Name of Owner/Applicant) Re: Onsite Wastewater Treatment System Inspection Information Request for: 3 l,a kan Q`w 72>r-Ln (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. 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. 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 15t 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 4 David Hatin, Director Building and Code Enforcement Town of Queensbury Property.Transfer Packet Revised April 2021 r Office Use Only r Permit#: "rowiof(juccnsbun• Fee: 742 Bay Road,Queensbury,NY 12804 P:518-761-8206 or 518-761-8205 Invoice#: i05� 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) 4 . Property address for inspection: Tax map number: Property owner: d an a ber I .� � Mailing Address (c/s/z): �3 o����U -Z Cell #: Land Line#: Email: �� a�U�e✓�� lm�r/, c,Q�yj Applicant (if different than above): Mailing Address (c/s/z): Cell #: Land Line#: Email: ❑ Proposed Owner ❑ Realtor ❑ Attorney ❑ Other (explain: ) Septic Contractor: AD/I?�/��Uyl Mailing Address (c/s/z): Cell #: Land Line#: Email: Y►i Reason for Inspection Request: ❑On the market ❑ Future listing ffSale Pending ❑ Deed Transfer ❑Other: Property Transfer Packet Revised April 2021 HOUSEHOLD INFORMATION "PLEASE SEE SEPARATE PAGE FOR EXEMPTIONS" # Bedrooms 4__# Bathrooms-3_— # Kitchens Jacuzzi tubs) Garbage grinder Onsite Wastewater Treatment System: How many systems are on the property? Year system(s) installed: Tank jq0L Size.of Septic Tank l�t� 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 [g No If yes, describe Maintenance: Service agreement? ❑ Yes j] No; If yes, business' name -Date of last inspection N/A ❑ Date tank last pumped ®l N/A ❑ Frequency of pumping f� /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 a No Seasonal ponding or breakout of leach field? ❑ Yes p' 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 bnsite 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: Eglowner 0 agent ❑other: Please print name: Signature: Date: 77 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 Jana Reiblein &Scott Nelson NMon2 '3 Lakeview Dr Queensbury, NY 12804To whom it may concern. The new septic system will be installed at the above address within property/deed transfer. We are closing on the property Friday,July 23,2021.The septic alteration permit has been issued and we are waiting on the contractor. For any further questions or concerns please contact us. Tjhank , f Ilana Reiblein (518) 578-3668 Scott Nelson (518) 791-1247 ARDI Notary Public,St late of New York No.01 GA6061460 Qualified in Warren Coun! 3 Cornmidvion Expires July 16 J ' 1- 02Z2- ZCZ,) 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: PLEASE CHOOSE ONLY ONE CONDITION BELOW IF YOU ARE REQUESTING A WAIVER ❑ 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 favor 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 of 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. JUL 21 2021 TOWN OF QUEENSBURY BUILDING&CODES Property Transfer Packet Revised April 2021 ❑ 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 anon-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. ❑ 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 must take place within one (1) year of submission of a completed application. Inspections scheduled to take place after the one year period will be subject to submission of a renewal application and payment of the renewal fee based on the current fee schedule. ***ONLY SIGN THIS PAGE IF YOU ARE OPTING FOR A WAIVER REQUEST!!*** I have read and understand the above notice regarding the expectations and possible forfeiture of moneys submitted to the Town of Queensbury for an exemption request. Seller: LL Print Name: Sign Name: Date: Bum CC. Print Name: Q-t I '1 Sign Name: Date: Property Transfer Packet Revised April 2021 �9 . • � �° � '�. `� �� � .��mod, do in ---�� � PJ ./ 17 TOWN OF QUFFNSBURY BUILDING 6 ZONING ' DEPARTMENT -SETV7AGF DISPOSAL PERMIT APPLICATION - 1. Ow-er' s Name .Address e'o-A&aaA 1/ A 7�,� ��:^� A/�7 /`✓ y / D. Telephone No. 713- 3/I c� 2. Property location 3 . Name of person. or firm responsible for ins.tallina. system OG S it/S , y1.5 Telephone No. 793�3118�✓ Address �G�I P IV �l�lvy 1�� �/ Cc%, V,_ -�. N./r 4. Number of bedrooms (residential buildings only) 5. Daily flow lJ crallons/day .. 6. Septic tank ca�city gallons 7 . Topography. flat,' rolling, steep slope • 1. . 8 . Nature of soil and depth / S 9. If ground water, bedrock or impervious material is .apparent at what roc depth does. it' begin. QI)ld f t. 10 . Percolation test: A is recuired B is not required C If -required what is the rate minutes/inch 11 . Water supply: municipal-; well, other l �� 12 . Type of system proposed: drywell, tile field , other- Any contractor, corporation, individual, etc. engaged in the construction -of a sanitary sewage disposal system who covers the same before inspection, does not have an approved permit, or varies from the approved appl-ication will be subject to a penalty of $250 as provided for in Section 6 . 010 of the Queensbury Sanitary Sewage Ordinance. l .t Date s' / aryl !%i� �CZ i signature of aplelicant On separate sheet of paper submit a diagram of the proposed septic system with all dimensions, including distance from ,any structure, distance from property line and domestic water supply, etc. Include all dimensions of the system itself. ^/ l � Form, 3-82 �- x '/