PT-0110-2022 1 ,
Property Transfer Sewage Disposal Information Form
Date:
Town of Qgeens6ary
742 Bay Road,Queensbury,NY 12804 S,e r+ lc e14"
P:518-761-8256 www.aueensbuiy.net 1
S-wOr d.P"k lkm 11-4 J V UY,h ams Res or-1`
(Name of Owner/Applicant) a
Re: Onsite Wastewater Treatment System Inspection Information Request for:
2� g q s -k f?4-. q L
(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 in of the current, or following year (whichever comes first), a map locating the septic
system and payment totaling$2275 ($2000 refundable deposit plus$275 permit fee). The deposit is forfeited
if the owner fails to complete the repairs or installation as stated above.
if you have any questions, please call.
Phone: (518)761-8256 Email: kated@queensbury.net
Thank you. a
Sincerely, A-14
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TOWN Oi B` IL 1 r�t;e do
QI11,(j�'c (;�2'tnY
David Hatin, Director
Building and Code Enforcement
Town of Queensbury
Property Transfer Packet Revised April 2021
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Office Use Only
Permit#:
Torn of'CLccnsbury Fee:_$
742 Bay Road,Queensbury,NY 12804
P:518-761-8206 or 518-761-8205 Invoice#:.
www.gueensbury.net 1/ I j perJ�l
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: 2 q 9 Rfi ' q I—
Tax map number:C 2-
a- % "'��•
Property owner: . yiord-hsk /R
Mailing Address(c/s/z):
2 y�R R+ 9 L, Lc,14e— 67e-0r tv i2 �Lf
Cell M.51 a 932 H ` 51 -Land Line#:-6-1 8� 6 5 6 9 2 L!Z
Email: 9 d rc�c�n ( � ymq I ���►-�
Applicant (if different than above): JV/A
Mailing Address(c/s/z):
Cell #: Land Line#:
Email:
❑ Proposed Owner ❑ Realtor ❑ Attorney ❑ Other (explain: )
Septic Contractor: T6 P
Mailing Address(c/s/z):
Cell #: Land Line#:
Email:
Reason for Inspection Request:
❑On the market ❑ Future listing XSale Pending ❑Deed Transfer ❑Other:
Property Transfer Packet Revised April 2021
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Manor/- -4c u5-c—
HOUSEHOLD INFORMATION
"PLEASE SEE SEPARATE PAGE FOR EXEMPTIONS"
# Bedrooms 3 # Bathrooms 3 # Kitchens Jacuzzi tub(s)O�_ Garbage grinder
Onsite Wastewater Treatment System:
How many systems are on the property?_L( r +h+s h.oVSG�
Year system(s) installed: Tank20I0 Size of Septic Tank -j:o0.0
Type of Absorption System:
Are all system components wholly wit 'n the property boundaries? es ❑ No
Are system plans available? '� � Yes ❑ No
Does the system(s) serve multiple properties? ❑ Yes ZIN o
If yes, describe
Maintenance:
7 ®u�e►AJ41 S11r i �U)L
Service agreement. [ Yes ❑ No; If yes, business name y)� 7�'h`'�
Date of last inspection N/A❑ Date tank last pumped 1Il2- 1 N/A❑
Frequency of pumping cat- N/A❑
List known repairs/replacements, with dates:
Date Type of Repair/Replacement
Operation:
System problems? ❑Yes M- No
Sewage odors? ❑ Yes
Direct surface discharge(s)? ❑ Yes wo
Back-up of toilets? ❑Yes "0
Back-up of any other fixtures? (e.g. slow drains) ❑Yes 040
Seasonal ponding or breakout of leach field? ❑ Yes �lo
Property Transfer Packet Revised April 2021
l9a Ie 3
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 p other:
Please print name: R1 C�, Gt rd6v)
Signature: /r d nQde✓ Date: bo 112-11—
V
Prior to scheduling with the Town of Queens bury, 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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252.-1-75.1 PT-0110-2022
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Dunham's Bay - Manager's House
2999 State Rte 9L
Property Transfer