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PT-0158-2022 Property Transfer Sewage Disposal Information Form ' Date: 2-©z-2--- 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: -- 141 Aann u - (Site Address for Inspection) Thank you for requesting an inspection for the onsite wastewater reatment 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 ist of the current, or following year (whichever comes first), a map locating the septic _system and payment totaling$2275 ($2000 refundable-deposit plus $275 permit fee). The deposit is forfeited if the owner fails to complete the repairs or installation as stated above. If you have any questions, please call. Phone: (518) 761-8256 Email: kated@queensbury.net Thank you. Sincerely, E rG I ro wo APR 0 4 2022 John O'Brien, Director Budding and Code Enforcement TOWN OF QUEENSEI IRY Town of Queensbury BUIL©ING R. CODEB Property Transfer Packet Revised February 2022 a Office Use Only Permit#: P1 "01`JS- 2022 ToLsm d(Laccnsbury Fee:_$ Zl�Xj 742 Bay Road,Queensbury,NY 12804 P:518-761-8206 or 518-761-8205 Invoice#: www.aueensbury.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: /l I /y 6nn`S Aa—� Tax map number: 2-3 00 :2 $ /6- - Property owner: ee-1_-7&j�Wdah2QLMin cS Mailing Address(c/s/z): 6-47L St,-4 ae 1Z8d Cell #: Land Line#: �/8 �g.Z �S Email: C%nril 11'1 e- c-�-D (. eDAI Applicant (if different than above): Mailing Address(c/s/z): Cell#: Land Line#: Email: ❑ Proposed Owner ❑ Realtor ❑ Attorney ❑ Other(explain: ) a Septic Contractor: &e'oej- Se-ri/!Ce-- Mailing Address (c/s/z): cs( ���Cl Cell#: (Jr/0 99i "0 960 Land Line#: Z �7L t / Email: 98,1 ?i ��E lam ' : MP-1 CfJr/� Reason for Inspection Request: Ef On the market ❑ Future listing ❑Sale Pending ❑ Deed Transfer ❑Other: Property Transfer Packet Revised February 2022 HOUSEHOLD INFORMATION "PLEASE SEE SEPARATE PAGE FOR EXEMPTIONS" # Bedrooms 2- # Bathrooms y # Kitchens Jacuzzi tub(s) Garbage grinder Onsite Wastewater Treatment System: J_re,94 y fidVaAe4 C'ivt ro -S 6� C ��° How many systems are on the property? Year system(s) installed: Tank 2-612— Size of Septic Tank if 000 A&A ec o� M& / / Type of Absorption System: _&sl) 6hv1r0AMeA_ ( r bl" Are all system components wholly ithin the property b'oundarf&W11 ies? ' �es ❑ No Are system plans available? Yes ❑ No `me- kD­'_ Z, �h ��• Does the system(s) serve multiple properties? ❑ Yes R No If yes, describe Maintenance: Service agreement? ❑ Yes E� No; If yes, business' name Date of last inspection N/A ❑ Date tank last pumped N/A ❑ Frequency of pumping N/A❑ List known repairs/replacements, with dates: Date Type of Repair/Replacement Operation: System problems? ❑ Yes 9No No ❑ Sewage odors? Yes Direct surface discharge(s)? ❑ Yes g No Back-up of toilets? ❑ Yes ['No Back-up of any.other fixtures? (e.g. slow drains) ❑ Yes d No Seasonal ponding or breakout of leach field? ❑ Yes M No Property Transfer Packet Revised February 2022 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: P,i1 a in P-,S Signature: Date: C Zv 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 February 2022