PT-0787-2021 Property Transfer Sewage Disposal Information Form
Date: aI
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 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$275 permit fee). The deposit is forfeited
if the owner fails to complete the repairs or installation as stated above.
If you have any questions, please call.
Phone: (518) 761-8256 Email: kated@queensbury.net
Thank you.
Sincerely, IE
E C E 9 W E
4 2 5 202�
David Hatin, Director TOWN OF QUEENSBURY
Building and Code Enforcement BUILDING&CODES
Town of Queensbury
Property Transfer Packet Revised April 2021
Office Use Only
Permit#: PT' o�I" '7DZ
hln o!'Qgecnsbun Fee:_$ 2 ,
742 Bay Road,Queensbury,NY 12804
P:518-761-8206 or 518-761-8205 Invoice#:
www.aueensburv.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: JJ�8- C �-e.J-erdde- j. ().Qe,0P1A /"y
Tax map number: / /f
Property owner:
Mailing Address (c/s/z):
Cell #: Land Land Line#:
Email jgm*Aabt-� 77&944,1[ C
Applicant(if different than above):
Mailing Address (c/s/z):
Cell #: Land Line#:
Email:
❑ Proposed Owner ❑ Realtor ❑ Attorney ❑ Other (explain: )
Septic Contractor: 1'10*1'-flow 0
Mailing Address (c/s/z):
Cell #: Land Line t
Email
Reason for Inspection Request:
❑On the market ❑Future Iisting,eSale Pending ❑ Deed Transfer ❑Other:
Property Transfer Packet Revised April 2021
HOUSEHOLD INFORMATION
"PLEASE SEE SEPARATE PAGE FOR EXEMPTIONS"
# Bedrooms 24 # Bathrooms # Kitchens J Jacuzzi tub(s)4?--( Garbage grinder
Onsite Wastewater Treatment System:
How many systems are on the property? �—
Year system(s) installed: Tank IL Size of Septic Tank
Type of Absorption System:
Are all system components wholly within the property boundaries? Yes ❑ No
Are system plans available? ❑ Yes �"o
Does the system(s) serve multiple properties? ❑ Yes ONo
If yes, describe
Maintenance:
Service agreement? ❑ Yes CQ'No; If yes, business' name
Date of last inspection N/A ❑ Date tank last pumped N/A ❑
Frequency of pumping 31 N/A ❑
List known repairs/replacements, with dates:
Date T e of Repair/Replacement
Le 20 d! C��v
Operation:
System problems? ❑Yes ;'?—No
Sewage odors? ❑ Yes No
Direct surface discharge(s)? ❑ Yes �K No
Back-up of toilets? ❑Yes .INo
Back-up of any other fixtures? (e.g. slow drains) ❑Yes No
Seasonal ponding or breakout of leach field? ❑ Yes 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: < )Cc `�U1
Signature: Date: lD tea,(
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
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APPROVED
Application
JUN 1 0 1993
Zngg Administrator , IT0AF O QUEENSBURY SL
North
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TOW OF QUEENSBURY BUILDING b CODE ENFORCEMENT './
531 Bay Road
Queensbury NY 12804
518--745-4447
SEPTIC DISPOSAL SYSTEM INSPECTION
Name✓�'�. .IZGIl1LGf�l2�r1u�,
Location
Date Permit # �13-a73
SOIL TYPE: Sand-Loam-Clay-
Results of Percolation Test-
(if applicable) Rate-Minute/Inch
TYPE OF SYSTEM:
ABSORPTION FIELD: Total Length
Length of each trench
Depth of trenches
Size of stone
SEEPAGE PITS: Number-
Size - ft. x ft.
Stone size
PIPING: Size Type
Bldg. to Tank
Tank to Dist. Box
Dist. Box to Field/Pit
Openings Sealed?* Yes-7-No Partial
LOCATION/SEPARATIONS: `I
Foundation tv Tank feet
Foundation to Absorption:` feet
Separation of Pies -' _ feet
Conforms as per Plot P/fan Yes No
LOCATION OF SYSTUM PROPERTY:
(circle one)
Front - Rear - Left Side - Right Side
Middle Front - `!;ddi e Rear
COMMENTS: /
SYSTEM USE APPROVED: YES NO
Arrived:
Departed:
Building I p for
2021
10
IT
,
RESOLUTION TO SET PUBLIC HEARING ON APPLICATION F(YW,VARIANCES'
FROM THE SANITARY SEWAGE DISPOSAL ORDINANCE FOR
MICHAEL AND BARBARA ANN MULDERRY
RESOLUTION NO. : E8, 93
INTRODUCED BY: Mr. Michel Brandt WHO MOVED ITS ADOPTION
SECONDED BY: Mrs. Susan Goetz
WHEREAS, the Town Hoard of the Town or Queensbury is, by
operation of Law, the Local Board of Health for the Town of
C,ueensoury and, as sucn, is authorized under Chapter 136 of the
Town of Queensbury On-51te Sewage Disposal broinance to issue
variances to such Ordinance, and
WHEREAS, Michael and Barbara Ann Muiderry have applied to
the Local Board of Health of the Town of Queensbury for a
variance from certain standards of the Town of Queensbury On—Size
Sewage Disposal Ordinance set forth in Cnapter 1.36, Hppenaix A,
such standards providing as follows :
APPENDIX A
TABLE I — HORIZONTAL SEPARATION DISTANCES FROM WASTEWATER SOURCES
iO STREAM
WELL OR LAKE OR
WASTEWATER SUCTION_ WATER PROPERTY LAKE
GEORGE
SOURCES LINE'(a) COURSE(c) DWELLING LINE AND
TRIGS.
Septic Tank 10, 10, "
NOW, THEREFORE, BE IT
RESOLVED, that the Local Board of Health for the Town of
Dueensoury will nold a puolic hearing on August c, 1993, az 7:00
p. m. , at the O ueensoury Hczivities Center, �reasonaoiy accessioie
to persons with mobility impairment ) 531 Bay Road, Town of
uueensbury, •barren County, New York, to consider tine application
for the variance of Michael and Barbara Ann Muiderry to place the
septic tank c' from tine property line and i' =rom the oweiiing,
rather than placing them at the mandated 10' distances, on
property situated at the end of Cleverdale ,Road (east side) , Town
of Queensbury, New York, and bearing Tax Map No. : Section 14,
Block c, Lot 5, and, at that time, all persons interested in the
subject thereof will be heard, and
RE IT FURTHER,
RESOLVED, that the Town Clerk of the Town of Queensbury be
ano is hereby directed and authorized, when in receipt of a list
of neighbors witnin 500 feet of the subject property, to puolisn
and provide Notice of said Public Hearing as may be recurred by
law, and authorized to mail copies of said Public Hearing Notice
to the adjoining neighbors.
Duiy aooptea tnis 17tn aay of juiy, 1:93, by the foilowing
vote .
AYES Mrs. Goetz, Mr. Caimano, Mr. Tucker, Mrs. Monahan, Mr.
Brandt
NOES None
ABSENT: None
I,Oarleen M.Oougher,Town Clerk of the Town of Queensbury,Warren County,
hew York,do hereby certify that I have compared the foregoing with the
original resolution as listed above adopted at a meeting
of the Town Board of the Town of Queensbury held on*e 1 1 day of
7s'--tA 19Qr] ,at which a quorum was present and that the
same is a correct transcript therefrom and of the whole original thereof
to date.
IN WITNESS THEREOF,I have herete set mil hand and the SEAL of said Town
of Queensbury,this day of f .191
SEA! SIGNED:
Darleen M.Dougher
Town Clerk
Town of Queensbury
.t
RESOLUTION APPROVING A 'SANITARY SEWAGE DISPOSAL VARIANCE
FOR MICHAEL AND BARBARA ANN Y
RESOLUTION NO. : 28, 93
INTRODUCED BY: Mr. Nick Caisano Ato
WHO MOVED ITS ADOPTION RCl) ece
i r
SECONDED BY: Mrs. Betty Monahan
WHEREAS, Michael and Barbara Ann Mulde viously filed a
request for two (2) variances from certain provisions of the Town
of Queensbury On—Site Sewage Disposal Ordinance, such provisions
being more specifically that requiring that there be a 10 foot
separation between the septic tank and the dwelling, and a 10
foot separation between the septic tank and the property line,
and
WHEREAS, a notice of public hearing was- given in the
official newspaper of the Town of Queensbury and a public hearing
was held in connection with the variance requests on August 2,
1993, and
WHEREAS, the Town Clerk advises that property owners within
500- feet of the subject property have been duly notified,
NOW, THEREFORE, BE IT
RESOLVED,
a) that due to tee nature of the variances, it is felt
that the variations will not be materially detrimental
to the purposes and objectives of this Ordinance or to
other adjoining properties or otherwise conflict with
the purpose and objectives of any plan or policy of the
Town of Queensbury;
b) that the Local Board of Health finds that the granting
of the variances is necessary for the reasonable use of
the land and that the variances are granted as the
minimum variances which would alleviate the specific
unnecessary hardship found by the Local Board of Health
to affect the applicant ; and
c) that the Local Board of Health imposes a condition upon
the applicants that they must also secure the approval
of the New York State Department of Health, and
BE IT FURTHER,
RESOLVED, that the Town of Queensbury Local Board of Health
grants the variances to Michael and Barbara Ann Mulderry,
allowing the placement of the septic tank :
mandated 10' distance ; and
2) 2' from the property line, , rather than placing it at
the mandated 10' distance;
on property situated at the end of Cleverdale Road (east side) ,
Queensbury, New York, and bearing Tax Map #: Section 14, Block 2,
Lot 5.
Duly adopted this 9th day of August, 1993, by the following
vote:
AYES: Mrs. Goetz, Mr. Caimano, Mr. Tucker, Mrs. Monahan, Mr.
Brandt
NOES: None
ABSENT:None
r
a
�3
TOWN OF Q UEENSE URY •
531 BAY ROAD, QUEENSBURY, N.Y. 12864-9725 (518) 745-4400
July 30, 1993
TO: Town Board Members
RE: Michael & Barbara Ann' Mulderry
Septic Variance
Dear Board Members :
In reference to the variance before you for the Mulderry's
to place holding tanks two feet from the property line and seven
feet from the dwelling, this Department has reviewed this
proposal and finds no other reasonable. alternative that could be
accomplished given the size of the property and the location of
the property on the point of Cleverdale.
The Board may not be aware but this residence sustained a
fire this past winter and Mulderry's are currently rebuilding on
this site and are proposing to eliminate a nonconforming septic
system and install holding tanks which would be much more
beneficial given the circumstances surrounding this property.
Unless the Highway Department objects to the holding tanks
being two feet from the property line, which would be basically
the Town road, I see no reason why the Board could not approve
this variance.
Should you have any further questions or comments, you may
wish to table this application, and I would be happy to attend
your next Town Board meeting and answer of those questions.
Si co ely,
C
DAVID HATIN, DIRECTOR
BUILDING & CODE ENFORCEMENT
DH:lm
"HOME OF NATURAL BEAUTY. . . A GOOD PLACE TO LIVE"
SETTLED 1763
RESOLUTION TO SET PUBLIC HEARING ON APPLICATION FOR VARIANCES
FROM THE SANITARY SEWAGE DISPOSAL ORDINANCE FOR
MICHAEL AND BARBARA ANN MULDERRY
RESOLUTION NO. : 28, 93
INTRODUCED BY: Mr. Michel Brandt WHO MOVED ITS ADOPTION
SECONDED BY: Mrs. Susan Goetz
WHEREA the Town Board of the Town of Oueensbury is, by
operation of Law, the Local Board of wealth for the Town of
Queensbury and, as sucn, is authorized under Chapter 136 of the
Town or Ouleensbury un-Site Sewage uisposai ureinance to issue
variances to sucn Ordinance, anc
WHEREA�, Michael and Barbara Ann Mulderry nave applied to
the Local Board of Health of the Town of Oueensoury for a
variance from certain stancaras of the Town or Queensoury On-Size
Sewage Disposal Ordinance set forth in Chapter 136, Appenaix A,
such standa ds providing as follows :
APPENDIX A
TABLE I - H RIZONTAL SEPARATION DISTANCES FROM WASTEWATER SOURCES
TO STREAM
WELL OR LAKE OR
WASTEWATER SUCTION WATER PROPERTY LAKE
GEORGE
SOURCES LINE(a) COURSE(c) DWELLING LINE AND
TRIBS.
Septic Tank
NOW, T EREFORE, BE IT
RESOLV D, thas the L-ocal Board of Health for the Town of
Oueensoury ill hold a puolic nearing on August 2, 1993, at 7:00
p- m. , at to a ueensoury Hctivities Center, treasonaoiy accessiole
sc persons with .nobility impairment ) 531 Bay Road, Town of
Queensbury, warren. County, New YorK, to conside^ the apoli-cation
nor T,ne variance of Michael and Caroa;^a Ann Muiderry to place the
septic tanH E, from the property iine and i' from the oweliing,
CL
TOWN OF QUEENSBURY
APPLICATION FOR SEPTIC DISPOSAL PERMIT Permit #
Fee Paid
7,1.
Date: Jov� ��993 ,!Reviewed By
o
awn o/Queen��d
LOCATION OF PROPERTY FOR INSTALLATION: �'( ��k �°gaZ tiny
Owner' s Name: \ �
Owner' s Mailing Address:
Installer's Name: Phone #:
Number of bedrooms (if residential ):
Total daily flow (residential-compute @ 150 gal . per bedroom) :
Topography-Circle One: Flat Rolling Steep Slope % of Slope
Soil Nature-Circle One: Sand Loam Clay Other /Depth:
Ground Water-At What Depth? Feet
Bedrock or Impervious Material-At What Depth? Feet
Percolation Test-Circle One: Not Required Required/Rate Min. Per Inch
Domestic Water Supply-Circle One: Municipal Well Other
If domestic water supply is a well -
Separation: Water supply from any septic absorption feet
PROPOSED SYSTEM: Septic Tank gal . (Minimum size: 1,000 gal . )
Tile Field: Each Trench feet//Total System Length feet
Seepage Pit(s): Number of / Size each: ft. x ft.
Size of Stone to be used: # / Depth or Thickness feet
**************
HOLDING TANK SYSTEM IF REQUIRED
No. of Tanks Size\of Each Gal .
Alarm system and associated electrical work to be inspected by a certified
agency.
I have read the regulation on the reverse side of this sheet and agree to abide
by these and all requirements of the Town of Queensbury Sanitary Sewage Disposal
Ordinance.
SIGNATURE OF RESPONSIBLE PERSON: �, DATE:,/
l/ '' I i_