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PT-0159-2022 Property Transfer Sewage Disposal Information Form low Date: 3) a,� Town of Queensbury 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.gueensbury.net -� Sep I ye Zed , U-e (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 11t 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, .WQ E� 'gURY John O'Brien, Director TOWS O 1NG COp�S Building and Code Enforcement gUv�-0 Town of Queensbury Office Use Only Permit#:�'• 0 I1' 2-o2,2- Tocsn rtP sbun Fee: 742 Bay Road,Queensbury,NY 12804 P:518-761-8206 or 518-761-8205 Invoice#: LC1-105 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: 3 lye i Q'ec's 10 Lw A'y 12a®q Tax map number: P-A-7 • ��— I '�� Property owner73 Sep-lye acoa LLr— ne Zcj-.-,e� P. jFvv—, �p Mailing Address (c/s/z): Lam - Sf• A-V'-F 3fz. NQ-kj /"-y ono 3 Cell #: �fL�"ZlO � �03� Land Line#: Email: LAC a '�3 see) e- @ a �o , C"n Applicant(if different than above): Mailing Address (c/s/z): APB27 4 �� Cell#: Land Line#: Email: TOWN OF OUBBNSBURY BUlL®lI�C��CODES ❑Proposed Owner ❑ Realtor ❑ Attorney ❑ Other(explain: ) Septic Contractor: Mailing Address (c/s/z): Cell#: Land Line#: Email: Reason for Inspection Request: ❑On the market ❑ Future listing ❑Sale Pending gDeed Transfer ❑Other: HOUSEHOLD INFORMATION "PLEASE SEE SEPARATE PAGE FOR EXEMPTIONS" # Bedrooms ro # Bathrooms S # Kitchens Jacuzzi tub(s) 0 Garbage grinder Onsite Wastewater Treatment System: How many systems are on the property? �(2�(�� S�� 6' !&C — 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 ® No 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? p Yes [3 No Sewage odors? ❑ Yes R No Direct surface discharge(s)? ❑ Yes [2 No Back-up of toilets? ❑ Yes Er No Back-up of any other fixtures? (e.g. slow drains) ❑ Yes ER No Seasonal ponding or breakout of leach field? ❑ Yes [ No 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: p owner ❑agent En other: Cc r u Please print name: 3 �el e � LL L El ` zah-e vaV-1s wta ki e4 9 � Signature: w'1�t,�=�— �4 -- Date: L30 1-AIJ- 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. Building & Code Enforcement 742 Bay Road, Queensbury, NY 12804-5902 Town of Queensbury P: 518-761-8256 www.gueensbury.net Notice of Violation March 16, 2022 Scott Evans 73 Seelye Rd LLC 79 Worth Street Apt 3R New York, NY 10013 Dear Mr. Evans , On December 28, 2021 you changed the deed.at 73 Seelye Rd in the Town of Queensbury. The Town of Queensbury has a requirement that prior to changing of the deed.of the property in aWater Front Residential Zone (WR-1A) you must obtain a permit to inspect the existing septic system by the Town of Queensbury as required by Chapter 137 entitled 'Septic System Inspection upon Property Transfer.' You have not submitted for the permit in order to do the inspection. This letter is to advise you that the inspection must be done within 6 months of this violation notice dated March 16, 2022 per Chapter 137-6 (A&B), see below. The compliance date is September 16, 2022. Please file for the permit and schedule an inspection before August 16, 2022. 137-6. Notice of Violation: penalties for offenses. If a property owner fails to complete an inspection required by the article, or to.allow access to the property for the required inspection,.or if the property owner fails to comply with any other provision of this article, a notice of violation may be issued by the Building and Codes Enforcement Office mandating the compliance with the inspection requirements. A.In the event the property owner in its capacity as grantor was issued a notice of violation and such violation continues fora period of six months, the current property owner (or grantee) too shall be deemed to be in violation of this article and may be subject to enforcement proceedings. B.An offense.against any provision of this article shall constitute a violation, punishable by a fine not exceeding $950, or imprisonment for a term not exceeding 15 days, or both. Each week such violation continues after notification to the person in violation shall constitute a separate violation. Thank you for your anticipated cooperation. 1 John O'Brien, Director Building and Codes Enforcement 5 V8-761-8255 johno@queensbury.net lisp CERTIFICATE OF COMPLIANCE, TOWN OF .WEENSDURY _ " WARREN, C6UN1'Y,• NEW'. YORK Date Septemb-,6y 25 19 9+6 95216 ' 'This fs 'to -certify' that work requested. to be done as shown by Pe•rmi t No. - .ha-s bee.n comple-ted... SEPTIC SYSTEM Thi s , ttructure, may be, used as a :Locatio.n{ 3 SE9I,EY ,R0 j 4!_r GREENS , ELEANOR H• o O.Wner, ,1 . By Order of Town. Bovard 1k` ILA P . N0 . Z 6 : -1-17 TOWN. OF QUEENSBURY Director of Bui 1 di ng A Code 'Enforcement y BUILDING -'PERMIT VALUE $ 0 • ,TOWN• * 9.5216--' TAX MAP NO.--- 16.-1-17--Y. No. WARREN COUNTY, NEW YORK . _ PERMISSION is hereby granted to . - GREENE, ELEANOR M- - 73 SEELEY RD. OWNER of property located,at Street,Road or Ave. -:- SEPTIC SYSTEM-- in the Town of Queensbury,To Construct or place a at the above location in accordance to application together with plot plans and other information hereto filed and approved and in compliance with the Town of Queensbury Building and Zoning Ordinance. 1. OWNER'S Address is BOX. 73>.,• :<-�-•-CLEVERDALE ,n 2. CONTRACTOR or BUI LDER'S Name ROULIER: ' JOE 3. CONTRACTOR or BUILDER'S Address 4. ARCHITECT'S Name 5. ARCHITECT'S Address 6. TYPE of Construction—(Please indicate by X) ( )Wood Frame ( ) Masonry ( )Steel ( ) I 7. PLANS and Specifications SEPTIC-SYSTEM TO INCLUDE: 1250 GAL::TANK-;::-U$;ING= -300�:2=0FY TILE V a; FIELDs.AS,-.PER:PLO.T-=PLAN_-.�sSPECIF•ICAT-IONS=_;;.: 8. Proposed Use ( SEPTIC. SYSTEM .FLU 1- 2 -cur SY- �_� _ L:��:Y.:� ..? -_. -?!r:Jti r�� t Aprilr27:.-�� � 97ut;= 'PERMIT-kE�RX =THIS i3ERl1'/IIT�EXPI 4s' ' 19 (If a longer period is required an application for an extension must be made to the Building and Zoning inspector of the town of Queensbury before the expiration date.) r=�T:�8 yf .. May. . - } 95.-:-.,.... _ Dated at the Town of Queensbury this �`��- _ -D'ay of - 19 SIGNED BY for the Town of Queensbury Building and Zoning I nalpeptor ut- pplication for f�P. TIC DISPOSAL, PERMIT STAMP RECEIVE D Location of property for,idsfallation: IS ���t e eves o N. . •:t PFRMI'I'NUMIl13R Owner's Name:. ���� �' eia,.►ur �.«.J Address: (D 00 Installer's Name: FEE PAID Phone #: Number of bedrooms (if residential): Total daily flow (residential -compute Q 150 gal. per bedroom): Topography: rla'1 Rolling [-71 Sleep Slope 4b of Slope Soil Nature: C6 Sand Q i.oam Q Clay 0 Other /Depth: (bound Water: at what depth? /Sr I'cct Bedrock or Impervious Material: at what depth? N � feet Percolation Test: Not Required Required/Rate min. per inch //++ Domestic Water Supply: C] Municipal 0 Well 0 Other _.S —ea �- If domestic water supply is a WELL: water supply from any septic absorption is feet PROPOSED SYSTTsM: Septic lank: "o gal. (ntinintum size: 1,000 gal.) 'life Field: each trench feet. / total system length feet. Seepage Pit(s): number of / size each: ft. a f[RE . CEIVEC Size of stone to be used: # / depth or thickness feet. AY 0 51995 Ii01.)ING 'TANK SYS'IUM:• (if required) N OF )UEEl+lBBUl3Y LDING AND CODE Number of tanks: Size of each: gal. Alarm system and associd(ed electrical work to be inspected by a certified agency. For your protection, please note that purstrant to Section 136-29 of the Code of the Town of Queensbury, any permit or approval grtrrtted which is based upon or is granted in reliance upon any material tit isrepresetildtion or ftrilttre to stake a material fact or circumstance knotivt by or on behalf of an applicant, shall be void. I have read the r egulations with respect to this application and agree to abide by these and all requirernettts of the Torun of Qtteensbury Sanitary Selvage Disposal Ordinance. Siettartme ofresponsible pers — Date: TOWN OF QUEENSBURY . BUILDING A CODE ENFORCEMENT 531 Bay Road Queensbury NY 12804, 518-745-4447 , . SEPTIC DISPOSAL SYSTEM INSPECTIOk Name �! Location DateC; APermit -� SOIL TYP : Sand-Loam-C1a Results of Per of ati on est- (if applicable Rate-Mi ute/Inch TYPE- OF SYSTEM ABSORPTION FIEL Total Length Length of each rench Depth of trenche Size of stone SEEPAGE PITS: Nu ber- Size - ft. x I ft. Stone size PIPING: Size Type Bldg, to Tank - Tank to Dist. Box Dist. Box to Field/P' Openings Sealed?' es No Partial LOCATION/SEPARATION : Foundation to Tank feet Foundation to Abso pti n feet Separation of Pits feet Conforms as per Plot P1 n Yes No LOCATION OF SYS ON P -OPERTY: .(circle on Front - ea - Le t Side Right Side Middle Front - Middle Rea COMMENTS: SYSTEM USE APPROVED: YE NO Arrived; ; U Departed: Building IdVpector O E w, (518)656-3544 O U LI ER� INC.C. BOX 301,CLEVERDALE.N.Y.12820 TOWN OF QUEENSBURY BUILDING DEPARTMENT Based on our limited examination, compliance with our comments shall not be construed as indicating the plans and specifications are in full compliance with the code. g 3 �a I ♦ 4---� s I pao pipe T WN OF ' 9 N U Y B ILDI� T 02 AAA `r W- RE iEWED B DATE RECEIVED MAY 0 51995 TOWN OF QUEENSB,,URY BUILDING AtJD C'.DE FILE COP Y - .