PT-0540-2022 1
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Property Transfer Sewage Disposal Information Form
Date: j
Town of Queensbury
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:
H6 _�L)CLIV)P11:�) P r_
(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 15t 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,
1�
John O'Brien, Director
Binding and Code Enforcement
Town of Queensbury
Property Transfer Packet Revised July 2022
Office Use Only
Permit#: OW '2D2,2—
Tosm o'ckwcns1 r 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)
Property address for inspection:
Tax map number: a1.3 —I—X31
Property owner:
Mailing Address (c/s/z): 'ALQ ,�Z������pZPLRCE . �•� .� �� � P
Applicant (if different than above): Q��
Mailing Address(c/s/z):
Cell #: nd Line#:
Email:
❑ Proposed O er ❑ Realtor ❑ Attorney ❑ Other (exp
AUG 3120�2
Sep_' _bn r-ac res �G��"io,�/�C- '5i - /d���' T gU pNGUEENSBVRY
Mailing Address (c/s/z): ' CODES
Cell #0_1f-.. X7- Land Line#:
Email:
Reason for Inspection Request:
❑On the market ❑ Future listing ❑Sale Pending ❑ Deed Transfer Other:
Property Transfer Packet Revised July 2022
HOUSEHOLD INFORMATION
"PLEASE SEE SEPARATE PAGE FOR EXEMPTIONS"
# Bedrooms # Bathrooms # Kitchens Jacuzzi tub(s) Garbage grinder
Onsite Wastewater Treatment System:
How many systems are on the property?
Year system(s) installed: Tank- $jw- e&Ei.ep-t4c-TLapik,�!- j
Type of=A-bs rp-ttc)hvS� Vol 1p s_$R
, cull 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 �o; If yes, business' name
Date of last inspection N/A ❑ N/A ❑
Frequency of pumping N/A ❑
List known repairs/replacements, with dates:
Date Type of Repair/Replacement
Operation:
System problems? ❑ Yes 4
Sewage odors? ❑ Yes No
Direct surface discharge(s)? ❑ Yes ❑ fy�
Back-up of toilets? ❑ Yes Z,16
Back-up of any other fixtures? (e.g. slow drains) ❑ Yes 2-
Seasonal ponding or breakout of leach field? ❑ Yes RrNo
Property Transfer Packet Revised July 2022
1 I
Statement of Acceptance of Conditions:
I agree to:
1
• Ensure that the septic tank(s), distribution bofles), 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 30% of the fee, is retained by the Town of
Queensbury.
Signature of property owner or authorized agent:
Affiliation: /owner ❑agent ❑ other:
Please print name: YAM`C.1 ., q?81�
Signature: �/�°� /�az9� 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 July 2022
r;
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gf� _Down ol Queenilury
UILDING and ZONING DEPARTMENT
If Bay and Haviland Road, R.D. 1 Box 98
I Queensbury, New York 12801
SEPTI ISPINSPECTION C OSALiSYSTEM
NAME
LOCATION JGI 7 ///
Z_X
DATE / PERMIT NO.
SOIL TYPE - Sand - Loam - Clay -
Percolation Test Required? YES - NO
Percolation rate - Min/Inch
TYPE of SYSTEM: /
Absorption field, total length
Length of -each trench
Depth of trenches ' Y/
Size of gravel'_ •`v _
A
SEEPAGE PITS4Numb of)
Size- ft. X _ ft.
Gravel size /
PIPING: S?'i T pe
Bldg. to tank-
Tank to dist. box ,>
Dist. box to field/.
Openings sealed? YES 0 Partial *
5
LOCATION/SEFARAT ONS:
Foundation to tank ft.
Foundation to absorption t.
Absorption to lot line f .
Separation of sits ft.
LOCATION OF S STEM ON PROPERTY(ci cle one)
Front - Rear Left side - Right s'de. =
COMMENTS:
e
SYSTEM USE APPROVED YES J)NO
Build ng fnspector
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DAT
APPLICATION FOR SEPTIC DISPOSAL PIs'RMIT Aim&owa coDEIDErr.
TOWN Of QUEMUftr
DA
LOCATION OF PROPERTY FOR INSTALLATION
Owner's Name: Rio Telephone: _
Address:
Installer's Name: Telephone: :2 9!3 2-29cD
Af
Number of bedrooms (residential only) _ �-
Total daily flow (compute @ 150 gal per bedroom) _
Topography: circle one: Flat Rolling Steep Slope io of slope
Soil Nature: circle one: EAan Loam Clay Other / Depth: feet
Ground Water: At what depth? feet
Bedrock or lmpe"ious Material: At what depth? feet
Percolation test: circle one: not required required / rate min. inch.
Domestic water supply: circle one: Municipal Well Other
IF domestic water supply is a Well:
Separation: Watersupply from Septic absorption _ feet
PROPOSED SYSTEM: Septic Tank 01,0dd gal. (minimum size: 1,000 gal.)
TILE FIELD: Each Trench << feet / Total system length feet
SEEPAGE PIT(S): Number of / Size each feet by feet
Size of stone to be used �P _ / Depth or Thickness feet
IMPORTANT
...Please...LIST NL•'W IsQU11�MI:N'i"1'O BB INSTALLED
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