PT-0018-2022 A
Property Transfer Sewage Disposal Information Form
Date:
Town of Queensbury
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.gueensbury.net
L/
(Name of Owner/Applicant)
Re: Onsite Wastewater Treatment System Inspection Information Request for:
Aln
(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,
4
David Hatin, Director
Building and Code Enforcement
Town of Queensbury
Property Transfer Packet Revised April 2021
l:
Office Use Only
Permit#: `y `ZO ZZ
Toism of 2irecnsbun f
Fee:
742 Bay Road,Queensbury,NY 12804
P:518-761-8206 or 518-761-8205 Invoice#: ��
www.gueensbury.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)
r Cc' err
Property address for inspection:
Tax map number:
Property owner: C[,WS 44-1
Mailing Address (c/s/z): _ MCell #: L -?, 7 S6 ,l Land Line#: _ Er, E � v E
ors c� D Email: c ®� FEB 0 2022
TOWN OE QUEENSBURY
Applicant (if different than above): BUILDING&CODES
Mailing Address (c/s/z):
Cell #: Land Line#:
Email:
❑ Proposed Owner ❑ Realtor ❑ Attorney ❑ Other (explain: )
Septic Contractor: T om ��� ►�`�
Mailing Address (c/s/z):
Cell #: Land Line#:
Email:
Reason for Inspection Request:
❑ On the market ❑ Future listing ❑Sale Pending ❑ Deed Transfer ❑ Other:
Property Transfer Packet Revised April 2021
HOUSEHOLD INFORMATION
"PLEASE SEE SEPARATE PAGE FOR EXEMPTIONS"
# Bedrooms # Bathrooms # Kitchens L— Jacuzzi tub(s),Garbage grinder Al�
Onsite Wastewater Treatment System:
How many systems are on the property?
Year system(s) installed: Tank Size of Septic Tank
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? ❑ Yes 4�END
If yes, describe
Maintenance:
Service agreement? ❑ Yes ❑ 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 . No
Sewage odors? ❑ Yes No
Direct surface discharge(s)? ❑ Yes No
Back-up of toilets? ❑Yes No
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: �ner ❑agent ❑ other:
Please print name:
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
July 14, 2021 F-r� E C 0 E
David Hatin, Director EJUL1 9 2021
Building and Code Enforcement TOWN OF QUEENSBURY
Town of Queensbury BUII-DING&CODES
742 Bay Road
Queensbury,NY 12804
RE: Property Transfer OWTS Exemption Request
34 Nacy Road SBL 289.6-1-20
Dear Mr. Hatin:
Enclosed please find the notarized affidavit of James and Rachel Kennedy(as Buyers) attesting to
their intent to fulfill the requirements of the Queensbury Onsite Wastewater Treatment System
Inspection Upon Transfer Law by completing the installation of a new OWTS at the above-
referenced parcel within six months of today's date. Also enclosed is the town's Exemption
Conditions Option form signed by the parties. An escrow fund has been created between the
parties to fund the anticipated work.
You may recall that Seller's attorney, Michael Borgos, had spoken with you about this project a
few weeks ago and related to you that P.E. Tom Hutchins has simply not had the time to complete
his work and obtain necessary permits and approvals and have the work completed prior to closing.
As you know, the industry is extremely busy right now and everyone involved is doing their best
to comply. It is our understanding that Mr. Hutchins has previously spoken with you about this
particular project. Per Mr. Borgos, you had directed that a notarized affidavit be provided by the
Buyers and submitted along with $2,000 to be held by the Town of Queensbury to guarantee
performance within six months. Enclosed you will find the affidavit, form and the check.
Upon completion of the work and final satisfactory inspection by your office,the funds on deposit
should be returned to the Sellers as follows:
Daniel and Penny Gravatt
246 Mill Stone Road
Perrineville,NJ 08535
Thank you.
EXEMPTION CONDITION OPTIONS
Due to one of the conditions listed below, I am requesting an exemption from the
Septic Inspection Upon Property Transfer by the Town of Queensbury:
PLEASE CHOOSE ONLY ONE CONDITION BELOW IF YOU ARE REQUESTING A WAIVER
❑ The property to be sold or transferred will not be inhabited,and the new owner plans to demolish the
existing.structure. In order to qualify for the exemption, a notarized affidavit must be submitted to the
Building and Codes Enforcement Office stating that the dwelling will not be inhabited and that it will be
demolished with no immediate plans to rebuild or the dwelling will not be inhabited, it will be
demolished and rebuilt, in which case the affidavit shall be accompanied by a site plan, including
adequate detail to demonstrate a lawful OWTS,together with a check payable to the Town of
Queensbury in the amount of$2,000.:Such funds will.be held in a non-interest-bearing escrow account
and will be released_ , in the former case,upon issuance of a,demolition permit and, in the,latter case,
upon issuance of a certificate of compliance from the Building and Codes Enforcement Office. If the .
Property.Transfer inspection is not:completed within-that 6 (six) month timeframe,
the $2000 will-be forfeited.
❑ An OWTS inspection'was not able to be completed prior to the conveyance of real property due to
inclement weather-In order to qualify for the exemption, a notarized affidavit from the new property
owner to complete the requisite OWTS inspection within six:months of the date of the conveyance of
Teal property, or June 1, whichever comes first, must be filed with the.Building and Codes Enforcement
Office. A check payable to the Town of Queensbury in the amount of$2,000 will be hold,in a non-.
interest-bearing escrow account and-shall be released upon the,completion of a satisfactory OWTS
inspection from the Building and Codes Enforcement Office. If the Property Transfer
inspection is not completed within that 6 (six) month or June 1" timeframe, the
$2000 will be forfeited.
The property,to be sold or transferred contains an existing OWTS that does not comply,with the
provisions of this article, and the prospective purchasers and/or the.Seller wish to forgo an inspection
in favor of installing an approved OWTS within six months of the transfer of property. In order to
qualify for the exemption, a notarized affidavit must be submitted to the Building and Codes
Enforcement Office stating that the existing OWTS will be replaced within six months from transfer of
property. The affidavit must be accompanied by a.site plan, including adequate detail to demonstrate
that the replacement OWTS will comply with this article, together with a check payable to the Town of
Queerlsbury in the amount of$2,000..Such funds will be held in a non-interest-bearing escrow account
and will be released upon,issuance of a certificate of compliance from the Building and Codes
Enforcement Office. If the Property Transfer inspection is not completed:within--that,6
(six) month timeframe,'the $2000 will be forfeited.
TOW,I )F QlJE1»NSEUM'
SUILDNO
Property Transfer Packet Revised April 2021
❑ During the.OWTS inspection, a failure of the septic system was determined. Due to winter and.
frozen conditions,the repair to an'existing OWTS could'not occur or a new OWTS could not be
installed.before the conveyance of real property. In order to qualify for the exemption, a notarized
affidavit.from the new property owner to'complete.the-installation or repair of the septic system.within
six months from the date:of the conveyance'.of real property; or June 1,whichever comes first,must,be
filed with the.Building and Codes Enforcement Office. A check payable to the Town of Queensbury in
the amount'of$2,000 will be held in a non-interest=bearing escrow account and shall be released upon
the completion of the repair or installation.of anew septic,system and a satisfactory'OWTS inspection -
from the Building and Codes.Enforcement office: If thie.Property Transfer.inspection is not
completed within that 6 (six):month or June 4st timeframe, the$1000 will be
forfeited.
❑ There is a record of a septic system inspection upon.propertytraiisfer permit and inspection completed
and passed within the last three years. Please provide a copy,of this record.
PLEASE READ NOTICE THOROUGHLY.
Failure to complete the inspectionj obtain the permit or complete all repairs/installations
identified in the preceding subsections-of this section within the time provided or-any subsequent
deadline established by the.Building and Codes Enforcement Off ce will.result in forfeiture.of the .
moneys held in escrow,and the Town may use such funds toward abating the conditions caused-
by each'such,violation-of this article: .
Inspections must take place within one (1)-year of submission of a completed.application.
Inspections scheduled to take place.after the one year period,will be subject.to. submission
of'a renewal-application.and payment of the.'renewal.fee.based_'on the currentlee schedule.
** ONLY SIGN THIS PAGE IF.'YOU ARE OPTING FORA WAIVER REQUEST!!***
I have.read and understand the above:riotice regarding the.expectations.and possible.forfeiture
of moneys submitted to the Town of.Queehsbury for an.exemption request.
Seller:-
.Print Name: . h; a
Sign Name: / i��iari��.�j� 6' :� Vol_CrO4_. :Date: /Y /
Buyer:
Print Name: .: ZwMex 91OeA=ff�4 A�&14 r/E.O y
JD Sign Name: . Date. 1
J
Property Transfer Packet Revised April 2021
AFFIDAVIT FOR OWTS INSTALLATION WITHIN SIX MONTHS
STATE OF NEW YORK )
) SS: C .� 0 V
COUNTY OF SARATOGA n
TOWN OFF CUED SBURY
JAMES KENNEDY and RACHEL KENNEDY, being duly swo de o` Vn ` a$_:,,�a ?==�
1. That we maintain a primary residence at-36 Piping Rock Circle, Saratoga Springs NY
... . ... ..._.... _.. - - _ _ _..._.. . .. .-
12866 and are under contract to purchase a vacation home identified as 34 Nacy Road in the
Town of Queensbury with a tax map number of 289.6-1-20.
2. That the Sellers, Daniel and Penny Gravatt, have disclosed to us that they retained the
services of NYS licensed professional engineer Tom Hutchins last fall to evaluate their system
prior to the listing of their property for sale, and that Mr. Hutchins recommended some
improvements and modifications be made prior to"the Queensbury OWTS inspection.
3. That we have been informed that Mr. Hutchins has been unable to complete the necessary
design work, obtain the necessary approvals and permits from the town and coordinate and
oversee the installation of the proposed improvements prior to the contractual closing of title due
to COVID-19 restrictions and subsequent workload volume constraints.
4. That we wish to proceed with the closing of title and have the work performed after
closing, and to facilitate same we have negotiated the creation of an escrow fund to be held by
our attorney, Amy Calabrese of Calabrese Law in Saratoga Springs,to provide the financial
resources to complete the project as soon as Mr. Hutchins can do so.
5. That we understand that the Town of Queensbury has a requirement that an exemption be
requested in order to perform the work and follow up inspection by the Town with the work
completed within six(6) months of closing.
6. That we further understand that in order to qualify for the exemption, a notarized
affidavit from Buyers attesting to the facts underlying the delay and inability to get the work
done to install the new OWTS prior to the conveyance of the real property is required and we
submit this affidavit to Mr. David Hatin, Director of Building and Codes, along with the
exemption form completed for that purpose.
7. That we also understand that a check payable to THE TOWN OF QUEENSBURY in the
amount of$2,000.00 must accompany the request for exemption with the funds to be held by the
town to motivate completion of the work within six months.
8. That we do hereby confirm that the property contains an existing OWTS that does not
comply with the provisions of the local law and that the parties wish to forego an inspection in
favor of installing an approved OWTS within six months of the transfer of the property.
9. That we seek a waiver of a requirement for a detailed site plan to accompany this request
for exemption since the delays occasioned by industry volume in the wake of the COVID-19
pandemic have prevented Mr. Hutchins from completing same and he may be contacted directly
for details of his current status of completion.
JAMS KENNEDY
RACHEL KENNEDY
worn o before me this
4t" da of July, 2021
ARY PUB 1qC
AMY CALABRESE
NOTARY PUBLIC,STATE OF NEW YORK
Registration No.02CA6105695
Qualified it Saratoga County .
Commission Expires Feb 17,20
I
1
SERVICE CONTRACT i
FOR THE f
FUJI CLEAN TREATMENT TECHNOLOGY
i
Ellsworth&Son Excavating,Inc.has been contracted by Fuji Clean USA and their Authorizer)Distributor to provide
you with the first two years of service, maintenance, and operation as well as any warranty service should it be
required.This contract has been paid in full on your behalf. This contract is provided in accordance with applicable
state and local regulations. !
This contract,entered into between Ellsworth&Son Excavating,inc.and James Kennedy shall be binding upon both i
parties in accordance with the conditions and temm set forth below: !
ii
Contract Date: December 2021 I
Term of Contract: 2 years I
I
Location of Technology:property address: 34 Nacy Road,Queensbury,NY 12804
Model: Fujlclean CE5
i
Maintenance and Other Services shall consist of. �
a. Inspection, Maintenance, and Operation: Service Provider agrees to inspect, maintain and operate the
Fuji Clean treatment system per the TN DEC and manufacturer's requirements.This includes but is not r
limited to the following:
two service visits per year (6-month intervals). Service visits will include performance of i
operation and maintenance activities detailed in the Operation and Maintenance manual;
check the sludge depth to determine the need for pumping;
inspection of the final effluent to determine proper operational performance;and I
test the process parameters including but not limited to DO, pH, and turbidity to maintain
proper operation;
b. Service Calls:Service Provider will provide services calls within two business days. Service Provider will j
apply a charge for labor,travel time and shipping for any necessary replacement parts unless covered by j
the manufacturer's warranty. I
c. Completed inspection form will be submitted to local and state authorities as required.
i
d. Contract is transferable in the event of sale of the home.
The owner of the system agrees to use the system as outlined in the owner's manual.The owner also understands
that any abuse of the system may void the manufacturers warranty.
Owner acknowledges that the following items can overtax the biological process of the system and shall avoid ,
introducing dental floss,disposable diapers,kitty litter,sanitary napkins,tampons,cigarette butts,condoms and other
items of similar nature. Owner acknowledges that the following can destroy the biological process and agrees to not
Introduce chemicals such as paints,varnishes,thinners,waste oils,photographic solutions,pesticides and excessive
amounts of household chemicals Into the system.The owner acknowledges that violation of these terms will void the
manufacturer's warranty and may be in A anon of state law.
Homeowner: Date (4 -Za Z�
Service Provider. . Date
(Autho zed Age
Please sign and return to the Service Provider whose name and address appear below:
Ellsworth&Son Excavating,Inc
10302 State Route 149
Fort Ann,NY 12827