PT-0667-2021 RECEIVED
Property Transfer Sewage Disposal Informati n Fo mS 0 2021
OUEENSBURY JUSTICE COUR'
Y/31 10 2,
I
Date.
T6wn of Qeensbary
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensburV•net
(Name of Owner/Applicant)
Re: Onsite Wastewater Treatment System Inspection Information Request for:
I Ia. 5c�� ✓I si� �9 '
(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 bestjob 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 11" of the current, or following year (whichever comes first), a map locating the septic
system and payment totaling$2275 ($2000 refundable deposit plus $275 permit fee). The deposit is forfeited
if the owner fails to complete the repairs or installation as stated above.
If you have any questions, please call.
Phone: (518) 761-8256 Email: kated@queensbury.net
Thank you.
tEEA E
Sincerely, 021
c sBos�Y
David Hatin, Director CODES
Building and Code Enforcement
Town of Queensbury
Property Transfer Packet Revised April 2021
Office Use Only
Permit#: �—boo
Wiunr
� Fee:_$ -
742 Bay Road,Queensbury,NY 12804 tt
P:518-761-8206 or 518-761-8205 Invoice#: �1
www.4ueensbury.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:. t12-- ln �1
Tax map number: Z —15
Property owner:
Mailing Address (c/s/z): Pb bz4s 4'I-"�
Cell #:`Jk8 • b8.1.1 ,2 Land Line#:
E-mail:
`Tyv 1(j �cijtily�V.•L01
Applicant (if different than.above):
Mailing Address (c/s/z):
Cell #: Land Line#:
Email:
❑ Proposed Owner - ❑ Realtor ❑ Attorney ❑ Other (explain: )
Septic Contractor: o 'c.
Mailing Address (c/s/z):
Cell #: Land Line.#:
Email:
Reason for Inspection Request:
On the market ❑ Future listing Nsale Pending ❑ Deed Transfer ❑Other:
\ Property Transfer Packet Revised April 2021
HOUSEHOLD INFORMATION
"PLEASE SEE SEPARATE PAGE FOR EXEMPTIONS"
# Bedrooms 0' # Bathrooms ' # Kitchens Jacuzzi tub(s) ® Garbage grinder
Onsite Wastewater Treatment System:
How many systems are on the property?
Year system(s) installed: Tank 10186 Size of Septic Tank
Type of Absorption System: (& .Q v voe I
Are all system components wholl withi the property boundaries? Yes ❑ No
Y p Y p p
Are system plans available? Yes ❑ No �f' ��ie�
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 ��C��1 N/A ❑
Frequency of pumping 3� s N/A ❑
List known repairs/replacements, with dates: AJ J (V E C) /1
'lop/
Date Type of Repair/Replacement
Operation:
System problems? El Yes
Sewage odors? ❑ Yes
Direct surface discharge(s)? ❑ Yes N
Back-up of toilets? ElYes ON
Back-up of any other fixtures? (e.g. slow drains) ❑Yes
Seasonal ondin or breakout of leach field? ❑ Yes No
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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 prop ty owner or authorized agent:
Affiliation: owner ❑agent ❑other:
Please print n me: -c'� 5� ��'""` `� E� �`4�
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 April 2021
�J®wn of 'Queengiur y
BUILDING and ZONING DEPARTMENT
Bay and Haviland Road, R.D. 1 Box 98
Queensbury, New York 12801
SEPTIC DISPOSALI SYSTEM INSPECTION
NAME
LOCATION.SvS o 4C. lV��•
DATE `1I 11 /RLm PERMIT NO.
SOIL TYPE - Sand - Loam - Clay
Percolation Test Required? YES -.NO
Percolation rate - Min/Inch
TYPE of SYSTEM:
Absorption field, totalg
Length .of;:rres
ch�trh"
Depth of
Size of ravel'_
SEEPAGE PITS4Number of)
Size- �ft. X ft.
Gravel size *
PIPINGV Size Type
Bldg. to tank
Tank to disc, box _
Dist. box to field/pit
Openings sealed? YES NO Partial
LOCATION/SEPARATIONS:
Foundation to tank jft.t-
Foundation to absorption `70 ft..-
Absorption to lot line ft.
Separation of pits ft.
LOCATION OF SYSTEM ON PROPERTY(circle one)
Front - Rear - Left side. - Right side -
COMMENTS:
/00() T. SIC
r/67 670 E oV6X
SYSTEM USE APPROVE YES NO
Building Inspe tor.
01/86 and vl
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- ouln. o` Queenjiury4 ,� zf APPLICATION FOR SEPTIC DISPQ ,
BUILDING and ZONING DEPARTMENT
4
Bay and Haviland Road, R.D. 1 Box 98 � •� ��+ � � la
Queensbury, New York 12801 DATE
LOCATION OF PROPERTY FOR INSTALLATION
/�r� L_��✓� t 1, �''�:,f Cr��. `7�",�"•� pl-�� �ri—��1%f��`z A ca e�r�� ���
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OWNER' S NAME ,):� �
ADDRESS C 4: d�� , 41✓ TEL rl 'o 0, 76
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INSTALLER' S NAME( °may , '
.�` =` ,t,�:at C,'': (� t/ Xf1. C?Ci'�;%C TEL
Number of bedrooms (residential only)
Total daily flow(compute @ 1.50 gal per bedroom)
Topography: Flat - Rolling % Steep slope - (circle one) % of slope
Soil nature: ,Sand '-(Loam%- Clay - Other Depth ft.
Ground water -At what depth? /_5 ft.
Bed-rock or impervious material - At what depth? ��! ft.
Percolation test required,,,= Required - -Rate min-inch.
Domestic water supply - Municipal -(We1l�) Other
Separation - Watersupply(if well) from Septic absorption ;; ft.
Proposed System: Septic tank jr GC? gala( Minimun size, 1000 gal. )
Tile Field - Each trench ft. Total system legnth ft.
Seepage pit(s) Number of Size each ft Xy` ft
Size of stone to be used # .,:_�• Depth or thickness ? ft.
IMPORTANT: '.
On a separate piece of paper, submit a diagram of the proposed system
with all dimensions shown; including distance from any structure ,
distance from property lines and from ANY DOMESTIC WATER SUPPLY or
shore-line of lake, strea-m,pond or wet-lands. Include all dimensions of
the system, itself .
I have read the regulations on the reverse side of this sheet and agree
to abide by these and aZZ requirements of The Town of Queensbvey
Sanitary Sewage L'isposaZ Ordinance.
Signature of responsible person
R
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05/86 and/vl
BUILDING PER1 T
TOWN OF QUEENSBURY No. 86=420
WARREN COUNTY, NEW YORK
PERMISSION is hereby granted to Lawrence and Joan King
OWNER of property located at 93 Sunnyside North Street, Road or Ave. t-
n
in the Town of Queensbury,To Construct or place a Sewage Alteration
at the above location in accordance to application together with plot plans and other information hereto filed and (oD
approved and in compliance with the Town of Queensbury Building and Zoning Ordinance.
P.
1. OWNER'S Address is RD #1 _ 93 Sunnys ide North o
Glens Falls, New York 03
2. CONTRACTOR or BUI LDER'S Name
Condon's Septic and Drain Service
3. CONTRACTOR or BUILDER'SAddress
Grant Ave.
Glens Falls, New York
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4. ARCHITECT'S Name
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N.
5. ARCHITECT'S Address a
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6. TYPE of Construction—(Please indicate by X)
(. )Wood Frame ( )Masonry. ( )Steel ( )
7. PLANS and Specifications
1000 gallon tank, 1 8'x10' drywell per plot and application
No.
rD
8. Proposed Use N
(D
Sewage system for dwelling a
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$ 10.00 PERMIT FEE PAID—THIS PERMIT EXPIRES July 24 19 88 w
(If a longer period is required an application for an extension must be made to the Building and Zoning inspector of the p
town of Queensbury before the expiration date.)
Dated at the Town of Queensbury this 24th Day of /July 1986
SIGNED BY Y f'1 ald 0� �" ' for the Town of Queensbury
Building and Zoning Inspector
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PROPERTY TRANSFER SEWAGE DISPOSAL INSPECTION LETTER
Satisfactory Compliance Notice
Town of Queensbury
Building&Code Enforcement
742 Bay Road,Queensbury,NY 12804-5902
P:518-761-8256 www.aueensbury.net
Date: 14 September 2021
To: Denise Zimmerman
(Applicant)
Re.: System Inspection Site Report for:
112 Sunnyside Rd N, Queensbury NY
(Site Address)
As requested, the Town of Queensbury's Building and Code Enforcement Department
has made an inspection of the wastewater system components serving the property referenced
above. All system components have been found, and are noted in the System Inspections
Findings Worksheet.
Inspector's observations:
The system appears to have functioned adequately under past and present loading.
There can be. no assurance or guarantee of future performance for any period of time.
Numerous factors, such as household water usage, leaking toilets, soil characteristics and
seasonal ground water table fluctuation, as well as owner failure to manage and maintain the
system, will affect its performance.
Sincerely,
44
David A. Hatin, Director
Building&Codes Enforcement
Town of Queensbury
/kd Revised.October 2020