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PT-0649-2021 Office Use Only Permit#: Town of[Zeensbun' Fee: 742 Bay Road,Queensbury,NY 12804 ,( G 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) Property address for inspection: 79 Knox Road Tax map number: 239.7-1-16 Property owner: Carol D. Collins and Renee D.West Mailing Address (c/s/z.): Lake George, NY 12845 � Cell#: Lan'd Line#: D � Email: aUG 1 "l e -�o\NN OF' ��,'ODES Applicant (if different than above): Thomas S.West, Esq. �uti_D Mailing Address(c/s/z): 575 Broadway, 2nd Floor,Albany, NY 12207-2931 Cell#:. 518-527-7240 Land Line#: Email: twest@westfirmlaw.com ❑ Proposed Owner Realtor ® Attorney Ej Other(explain: ) Septic Contractor: unknown Mailing Address (c/s/z): Cell M Land Line#: Email: Reason for Inspection Request: ❑On the market ❑Future listing Rx Sale Pending ❑Deed Transfer ❑Other: Property Transfer Packet Revised April 2021 HOUSEHOLD INFORMATION **PLEASE SEE SEPARATE PAGE FOR EXEMPTIONS** # Bedrooms 5 #:Bathrooms 3 # Kitchens 1 Jacuzzi tub(s) 0 Garbage grinder 0 Onsite Wastewater Treatment System:. How many systems are on the property? 1 Year.system(s) installed: Tank 1970s Size of Septic Tank loon gallons Type of Absorption System: dry wells Are all system components wholly within the property boundaries? ❑x Yes [] NO Are system plans available? ❑ Yes ❑x No Does the system(s) serve multiple properties? ❑ Yes © No If yes, describe Maintenance: Service agreement? p Yes x❑ No; If yes, business' name Date,of last inspection- 2019 N/A❑ Date tank last pumped 2019 N/A ❑ i Frequency.of pumping 2-3 years N/A❑ List known repairs/replacements, with dates: Date Type of Repair./Replacement Operation: System problems? ❑Yes ❑x No Sewage.odors? ❑ Yes ® No Direct surface discharge(s)? ❑ Yes ® No Back-up.of toilets? ❑Yes x❑ No Back-up of any other fixtures? (e.g. slow drains) ❑Yes x❑ No. Seasonal ponding or breakout of leach field? El Yes ❑x 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: ❑ow ❑x agent ❑other: Please print ho s S. west Signature: Date: Aug. 27, 2021 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 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 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 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 V timeframe, the $2000 will be forfeited. 1K1 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 Queensbury 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. 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 a new septic system and 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 Ist timeframe, the $2000 will be forfeited. ❑ There is a record of a,septic system inspection upon property transfer 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 inspection, 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 Office 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 current fee schedule. ***ONLY SIGN THIS PAGE IF YOU ARE OPTING FOR A WAIVER REQUEST!!*** I have read and understand the above notice regarding the expectations and possible forfeiture of moneys submitted to the Town of Queensbury for an exemption request. Seller: Print Name: Carol D. Collins Sign Name: _ Date:Aug. 27, 2021 Buyer: Print Name: Renee D. West, Sign Name: ZJ Date:Aug. 27, 2021 Property Transfer Packet Revised April 2021 "3� 1 E 21AFFIDAVIT SURYSTATE OF NEW YORK ) DrSss.. .,- -- -- COUNTY OF WARREN Ren6e D. West, being duly sworn, deposes and says: 1. I am the co-owner of the premises located at 79 Knox Rd., Queensbury,NY 12845,Tax Paarcel 239.7-1-39, and am in the process of purchasing the remaining interests in the premises. 2. I make this affidavit-in furtherance of compliance with Section 134,of the Official Code of the Town of Queensbury,New York,relative to transfers of properly in certain districts within the Town. 3. Our septic system is over 40 years old. Although we maintain it regularly and we believe it to be in good operating order,to be good stewards of Lake George,we are planning to upgrade the system to a modern septic system. 4. Pursuant to Section 137-4(C) (3),I make this affidavit to confirm that we will permit and install a new septic system within six months after the transfer of the premises. We have already engaged Dennis MacElroy as a consulting engineer to design the system and he has prepared a preliminary design that we have approved. 5. The house on the premises is not winterized. Consequently,it will not be inhabited from October 5,2021,through mid-May of 2022. 6. We are depositing a$2000 deposit with this affidavit. Wherefore,your deponent respectfully requests approval to complete the transfer of the premises. 17 6e D. Wes Sworn to before me this �Dfh day of August,2021. otary Public THERESA M.KACZOR Notary.Public,State of New York No.01KA6332465 Qualified in Schenectady County Commission Expires November 2,20-6,3 Thomas S.West THE' T IRM Direct Dial: (518)641-0501 AraorEsSION wnco�irArw E-Mail: twest@westfirmlaw.com Admitted in New York February 14, 2022 VIA FIRST CLASS MAILIFEB �' IE R'. Hon'. John Strough and Members of the Town Board ,,i� 742 Bay Road JE BUlQueensbury,NY 12804C71", Supervisor Strough and Members of the Town Board: This past September,my wife purchased a 50%interest in the property located at 79 Knox Rd.,Queensbury,NY 12845. This brought her total ownership of that property to 100%. Pursuant to Section 134 of the Official Code of the Town of Queensbury,New York, she deposited$2000 with a commitment to upgrade the septic system at the property. As we are in the middle of winter conditions, we would like to extend the time to replace the existing septic system for an additional six months. You should be aware that we are working with a local engineer to design a state-of-the-art septic system involving.the FujiClean technology, which is the best available technology. You should also be aware that we are looking for options to winterize the existing residence and it would be best to do both projects together. Pending installation of the new system, we will continue to maintain the existing system in good working order. Thank you for your consideration of this request. V�I t r y yo rs, s W tT �A cc: David Hatin,Building Inspector Attorneys and Counselors at Law Peter Kiernan Plaza 1 575 Broadway,2°d Floor I Albany,NY 12207-2931 Office: (518)641-0500 Fax:(518)615-1500 www.westfirmlaw.com SEWAGE DISPOSAL SYSTEM EXEMPTION COMPLIANCE LETTER Town of Queensbury 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.aueensbury.net Date: 8 September 2021 To: Thomas and Renee West (Requestor) Re: System Inspection Site Report for: 79 Knox Rd, Lake George, NY 12845 , (Site Address) The buyer of the above-referenced parcel has submitted to the Town-of Queensbury an exemption request Which includes a notarized letter stating the existing septic system will be replaced within 6 (six) months from the date of the transfer of deed. The buyer has submitted a waiver deposit of$2000.00, as well as paid the $275.00 inspection fee. If, however,the new OWTS has not been installed with passing septic inspections within the same 6 (six) month timeframe,the $2000.00 waiver deposit will be forfeited. Sincerely, 4 David A. Hatin, Director Building& Code Enforcement Town of Queensbury /kd Building&Code Enforcement ��� -I-JI L-T -E- TOWN DF QUEENSBURY ---B-U-ILDING&CODES