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PT-0300-2022 Property Transfer Sewage Disposal Information Form Town of Queensbury Date: 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. Priorto 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 $275 permit fee). The deposit is forfeited if the owner fails to complete the repairs or installation as stated above. If you have any questions, please call. Phone: (518) 761-8256 Email: kated@queensbury.net Thank you. Sincerely, p E C E a V IE MAY 18 2022 TOWN OF QUEEIVSBURY John O'Brien, Director BUILDING & CODES BuJding and Code Enforcement Town of Queensbury Property Transfer Packet Revised February 2022 Office Use Only Permit#: 6 bOO'-20 2,2 Town of cLuccnsbur, Fee:_$ Z 742 Bay Road,Queensbury,NY 12804 P:518-761-8206 or 518-761-8205 Invoice#: Leto 1. www.clueensbury.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: 1-7 Tax map number: _ — p Property owner: � fl �jrjt9� Mailing Address (c/s/z): 5—4r)[,- Cell#: 5 19,4-_�'a142R'i19 Land Line#: Email• ��� ��� D Applicant (if different than above): MAY 18 2022 Mailing Address (c/s/z): - TOWN OF QIJCENSBU Cell #: F''� Land Line#: BUILDING& CO®EERY Email: ❑ Proposed Owner ❑ Realtor ❑ Attorney ❑ Other(explain: ) Septic Contractor: Mailing Address (c/s/z): Cell#: Land Line#: ,5b IC11 Email: Reason for Inspection Request: ❑ 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 3# Bathrooms I # Kitchens__�_ Jacuzzi tub(s) 9— Garbage grinder Onsite Wastewater Treatment System: How many systems are on the property? Year system(s) installed: Tank ti Size of Septic Tank 100� Type of Absorption System: ��y__tt>Are all system components wholly within the property boundaries? 6-Yes ❑ No Are system plans available? 0 Yes ❑ No Does the system(s) serve multiple properties? ❑ Yes No If yes, describe Maintenance: Service agreement? ❑ Yes /No; If yes, business' name GGO `r1 6V'5 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 S No Sewage odors? ❑ Yes ta 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 I, No Property Transfer Packet Revised February 2022 =r 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: 15a owner ❑ agent ❑other: Please print name:� ���P�� ��I Signature: Date: fat 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 4 ofX TOM OF Q UEENSBURT � BUILDING $ CODE ENFORCEMNT 531 Bay Road Q uee�sbury BAY I2804 518-745-4447 SEPTIC DISPOSAL SYSTEM INSPECTION Name Location. Date Permit SOIL TYPE: Sari -Loam-Clay- Results of Percolation Test- (if applicable) Rate-Minute/Inch. 1 TYPE OF SYSTE l.- ADSORPTION'EIELD: Total Lengt. Length:of each trench Depth of_trenches .Size of stone . SEEPAGE PITS: Number- j Size �a ft. r. '' ft. Stone size M"2 PIPING. JSize Type Bldg. -to Tank' "60A XA© Tank to Dist. Box Dist. Box to Fie Openings Sealed.? . es �o Partial LOCATION/SEPA ICES: Foundation to ank feet Foundation to Absorption ox feet Separation of Pits� eet Conforms as per Piot Plan LOCATION OF SYSTEM ON PROPERTY.- . (circle one) Front - Rear - .Left Side - Right Side Middle Front - , dle Rear COMMENTS: SYSTE14 USE APPROVED: YES NO Arrived- Departed. ding Inspec j i0 4 '/ /ova 1 TOWN OF QUEENISSURY' 04 EPT- REVIEWED B ,y DATE � T Y TOWN OF QUEENSBURY 11 ft;i APPLICATION FOR SEPTIC DISPOSAL PERMIT Permit # _qOA Fee PaidP �1 9 Date: Reviewe �ctiBy LOCATION OF :PROP.ERTY FOR INSTALLATION: ' co Owner' s Name: ®/lu �413�, Owner' s Mailing Address: ,,c1 � � P Installer' s Name: '%/ � Phone #: � �'.72 �7 Number of bedrooms (if residential 2, Total daily flow (residential-compute @ 150 gal . per bedroom) : -?o o Topography-Circle OneoSan Rolling Steep Slope % of Slope Soil Nature-Circle OnLoam Clay Other /Depth: Ground Water-At What- Depth? Feet Bedrock or Impervious Material.-At What Depth? Feet - Percolation Test-Circle One: Not Require-d . Required/.Rate Min. Per Inch Domestic Water Supply-Circle One: unici al Well Other _ If domestic water supply is - Separation: Water supply from. any septic absorption feet PROPOSED SYSTEM: . Septic Tank ®0+� gal . (Minimum size: Y,000 gal.. ) Tile Field: Each Trench feet//Total System Length feet ' Seepage Pit(s) : Number of / Size each: ft. .x OCI- ft. Size of Stone to be used: # Depth or Thickness feet HOLDING TANK SYSTEM IF REQUIREp 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 Town of Queensbury Sanitary 'Sewage Disposal Ordinance. SIGNATURE OF RESPONSIBLE PERSON: DATE: I EML GOP)�� AS BUILT L -roVVN OF QU BUILDING & Reviewed B Date: TS 29 30 a, QUEENMPLY E LA I L C) R-OViEWED P DATE