PT-0405-2022 Property Transfer Sewage Disposal Information Form
Town of Queensbury Date: (o Z7—2Z
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:
a
(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 Vt of the current, or following year (whichever comes first), a map locating the septic
system and payment totaling$2275 ($2000 refundable deposit plus $275 permit fee). The deposit is forfeited
if the owner fails to complete the repairs or installation as stated above.
If you have any questions, please call.
Phone: (518) 761-8256 Email: kated@queensbury.net
Thank you.
Sincerely,
CER
John O'Brien, Director
BUJ'ding and Code Enforcement JUN 29 2022
Town of Queensbury
TO UN DING QUEENSBURY
- a. CODES
Property Transfer Packet Revised February 2022
Office Use Only
Permit#: -��OS'2022
Tone of C�rccnsbuty Fee:
742 Bay Road,Queensbury,NY 12804
P:518-761-8206 or 518-761-8205 Invoice#: 51
www.gueensbury.net
SEWAGE DISPOSAL SYSTEM INSPECTION INFORMATION
Individual Residential Wastewater Treatment System
CONTACT INFORMATION (please print legibly or type and include an email address)
Property and Owner Information: (Please attach property survey or tax parcel map)
Property address for inspection:
Tax map number: ZZ4=-.4Z
Property owner:
Mailing Address (c/s/z): GI Co�a c17a1�Jt�2�'1��1� Kew �i�-►r4i�� CT
Cell #: q l7 Land Line#:
Email:
Applicant (if different than above):
Mailing Address (c/s/z):
Cell #: Land Line#:
Email:
❑ Proposed Owner ❑ Realtor ❑ Attorney ❑ Other (explain: )
Septic Contractor: CZAJ-4 �t41_L
Mailing Address (c/s/z): �3 \Pjoo:bc.4*� 41�` �� b"?�' E Y-Ly
Cell #: _!5t$ A7D—HCAA4 Land Line#:
Email chi t Grcvnc'k�l I �c►� �c�,m.�� _cam
Reason for Inspection Request:
❑On the market ❑ Future listing ❑Sale Pending KDeed Transfer ❑.Other:
Property Transfer Packet Revised February 2022
HOUSEHOLD INFORMATION
"PLEASE SEE SEPARATE PAGE FOR EXEMPTIONS"
# Bedrooms (_,o# Bathrooms -3 # Kitchens ` Jacuzzi tub(s) Garbage grinder
Onsite Wastewater Treatment System:
How many systems are on the property?
Year system(s) installed: Tank Size of S is Tank tAC.-
Type of Absorption System:
Are all system components wholly within the property boundaries? Fjj es ❑ No
Are system plans available? MOO'Yes ❑ No
Does the system(s) serve multiple properties? ❑ Yes Mr/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? ❑ Yes ❑*No
Sewage odors? ❑ Yes Z No
Direct surface discharge(s)? ❑ Yes EeN0
Back-up of toilets? ❑ Yes ZNo
Back-up of any other fixtures? (e.g. slow drains) ❑ Yes EdNo
Seasonal ponding or breakout of leach field? ❑ Yes VNo
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 Vagent ❑ other:
Please print name: IS tAA�EL-IF�' -Y-
Signature- l Date: �—Z7—ZZ
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
ENVIRONMENTAL DESIGN
PARTNERSHIP, LLP. 900 Route 146 Clifton Park,NY 12065
(P)518.371.7621 (F)518.371.9540 edpllp.com
Shaping the physical environment
August 12, 2022 n
Town of Queensbury Building&Codes
742 Bay Road AUGQueensbury, NY 12804 2022
Attn: John O'Brien ?'Owhl Of- QD�r
E3fU�DIN(3 '=1 "3BURY
ODE,
Re: Griffiths Residence Wastewater—298 Cleverdale Road.
Dear John:
In compliance with approvals granted by the Town of Queensbury 1 offer the following regarding the
referenced project. The Griffiths property consists of a single-family residence and a detached
"bedroom cottage", both served by an existing holding tank system (2-2,000 gallon concrete tanks—
4,000 gallon total capacity). The main house has a grinder pump assembly which pumps wastewater
to one of the holding tanks(east tank)and the cottage flows discharge by gravity to the other
holding tank(west tank). The two tanks are connected in series so that all flows `equalize'within
both tanks.
On July 26,2021 the Queensbury Board of Health approved a requested variance for the continued
use of the existing holding tank system at the 4,000-gallon capacity provided. EDP was involved in
the replacement of the antiquated grinder pump system with a new duplex grinder pump and
controls assembly as an "in-kind" replacement. No permit was required by the Town Building
Department. The replacement system consists of a fiberglass tank with a duplex grinder pump
assembly located just outside the renovated foundation of the south side of the house. The control
panel is located within a first-floor closet also housing the electrical panel. Attached for the files is
an 'as-built'sketch of the wastewater system added to the survey provided by Darrah Land
Surveyors.
During the course of construction, I was on the job site to observe key components of the system
installation culminating with the start-up of the pump assembly and control panel system on June
30,2022. 1 also participated in the Town's `Property Transfer Inspection'which concluded on
August 3,2022 with confirmation that all flows from the main house and the cottage are property
connected to the holding tank system. We also confirmed the replacement of the holding tank alarm
panels.
Based on my inspection of the system start-up it is my opinion that the wastewater system is in
compliance with the intent of the design and is ready for operation.
Sincerely,
Dennis MacElroy, PE
attachment
cc: Harley Griffiths