PT-0719-2021 Property Transfer.Sewage Disposal Information Form
Date:
Town of Qgeensbury
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:
(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 applicatiori,•a site'rnap indicating the location of the septic components and confirmation the
pre-inspection preparation (see the last page of this packet) will be co pleted 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 151 of the current, or following year (whichever comes first);-a map locating the-septic
: system and payment totaling$2275 ($2000 refundable deposit plus$275 permit fee). The deposit is forfeited
if the owner fails to complete the repairs or installation as stated.above.
If:you have:any questions, please call.
Phone: (518) 761-8256 Email: kated@q.ueensbury.net
Thank you:.
Sincerely,
David Hating Director.
.Building and Code Enforcement:
Town of Queensbury
Property Transfer Packet . . Revised April 2021
Office Use Only
Permit#:
Town ofgiMcn bury Fee:_$
742 Bay Road,Queensbury,NY 12804
P:518-761-8206 or 518-761=8205 Invoice#:A�
www.uueensbury.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 ro attach pperty,survey or taz parcel map)
�Property address for inspection: �� / �v : ('01nC
Tax map number:
Property owner:.
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q ))��� �,5 ✓o 5 UV i
Mailing Address (c/s/z): Zo 111 e,
Cell #:,()-A 1)U �r,>13 Land Line-#: CdT .
Email: a MOC
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Applicant (if different than above):
Mailing Address (c/s/z):
SEP 29 2021
Cell#. Land Line#:
OWN OF QUEENS13URY
Email: : BUILDING& CODES .
❑ Proposed-Owner ❑ Realtor ❑ Attorney ❑ Other (explain: . )
Septic Contractor:
Mailing Address (c/s/z):
Cell:#: Land Line#:
Email:
Reason-for Inspection Request:
❑.On the market ❑ Future listing ❑Sale.Pending` Deed Transfer ElOther:
Property Transfer Packet Revised April 2021
HOUSEHOLD INFORMATION
"PLEASE SEE SEPARATE:PAGE FOR EXEMPTIONS".
# Bedrooms # Bathrooms . #Kitchens Jacuzzi tubs) Garbage grinder �—
Onsite.Wastewater Treatment System:
How many systems are on the property?,�
Year system(s),installed: Tank Afo�)L,• Size of Septic Tank/R 0.�.
V
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? ,0 Yes : No
If yes, describe
Maintenance:
. ' Service agreement? ❑ Yes No; .lf.yes, business' name
Date of last'inspection N/A Date tank last pumped
Frequency of pumping N/JM
List known repairs/replacements,,with dates:
Date- Type.of Repair/Replacement :.
Operation:
System problems? ❑Yes No
Sewage odors? ❑ Yes 15 , No
Direct surface discharge(s)? ❑ Yes No
. Back-up of toilets? ❑.Yes No
Back-up of any other fixtures? (e.g. slow drains)„ ❑Yes . 'K No
Seasonal ponding or breakout of leach field? ❑ Yes- No
Property Transfer Packet. Revised April 2021
ditions:Statement of:Acceptance of Con
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 thetank 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 interiorplumbing in crawl spaces and basements.
p.
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.
9
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 Tow.n:of
Queensbury.
s
Signature of property owner or authorized agent::
Affiliation: 'owner . ❑ agent other:,..
:.Please print name: 1 "
Ire 3 U�
q .
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
an.y.seepage pit covers. .. _:.
3..Excavate test hole in leach field if there is no d-box.
Property Transfer Packet Revised April 2021
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