PT-0606-2022 � - Office Use Only
Permit#:
rotsm of Queens T Fee:_$
742 Bay Road,Queensbury,NY 12804
P:518-761-8206 or 518-761-8205 Invoice#: �6
www.gueensburV.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: �� l • ��� �rJ
Property owner: BW UL
Mailing Address (c/s/z): ` ► I �,C '
Cell#. 1 0 3(Pl Land Line,#:
Email: ryvA45 lad & t. ailn
E, CE9 V E
Applicant (if different than above):
Mailing Address (c/s/z):
SEP 2 9 2022
Cell #: Land Line#: k
WN OF CZUBEP�!SBURY
BUILDI & CODES .
Email:
❑ Proposed Owner ❑ Realtor ❑ Attorney ❑ Other(explain:
Septic Contractor: r,i
is
Mailing Address (c/s/z): 1 I-7 WY 1
Cell#: Land Line#:
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 # Bathrooms # Kitchens ) Jacuzzi tub(§) Garbs e ririder
g g
Orosite Wastewater-Treatment System:
How many systems are on the property? l
Year systems) installed: Tank Size of Septic Tank ��.�. l' ,
' '
Type of=Absorption System 160 W
Are all system components wholly within the property boundaries? E�s ❑ No
.. Are system plans.availableT ,❑ Yes [g,/No, ,
Does the system(s) serve multiple properties? ❑ Yes '-E2/No
If yes; describe
Maintenance:
i .
Service agreement? ❑ Yes No; If yes, business' name
Date of last inspection N/A L2' Date tank-last;pyMped N/A FQ�-/
Frequency of pumping at N/A
List known.repairs/repiacements, with dates:
Date Type of Repair/Replatement
Operation: -
System problems? ❑ Yes. . . I No
Sewage odors?.. p Yes I I No,.
Direct surface.discharge(s)? ❑ Yes 149
Back-up of toilets? ❑;Yes No.
Back-up of any other fixtures? (e.g. slow drains) ❑ Yes I No
Seasonal ponding or breakout of leach field? ❑. Yes No
Property,Transfer Packet Revised February 2022
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