PT-0571-2022 Property Transfer Sewage Disposal Information Form
- Date: IM1�U�2
Toivn of( ueensbur.v
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 _Y_y.Ya.y4trii�Jui y.(tc l
Ue-o-n D. kD-6n -Tres Mev- Val-,h
(Name of Owner/Applicant)
Re: Onsite Wastewater Treatment System Inspection Information Request for:
J�i c? �11 10i KIC t200 d
(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 11 of the current, or following year (whichever comes first), a map locating the septic
system and payment totaling$2275($2000 refundable deposit plus$275 permit fee). The deposit is forfeited
if the owner fails to complete the repairs or installation as stated above.
If you have any questions, please call.
Phone: (518)761-8256 Email: kated@queensbury.net
Thank you.
Sincerely,
i '; :fi 1 ;(; •
!',BEN,
l
John O'Brien,Director
Building and Code Enforcement
Town of Queensbury
Property Transfer Packet Revised July 2022
Office Use Only
Permit#: -0`J�-'1- 2p2 -
r<.w„ Fee:_$ Z
742 Bay Road,Queensbury,NV 12804
P:518-761-8206 or 518-761-8205 Invoice#: 5
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:_ri-+9 P,, 64 164 RoaJ K* -rukl/ Nyta&y
Tax map number:
Property owner: 73i20.n 0. Ka-�n -Truz+ -I
O
Mailing Address(c/s/z):_ �.0.130)c 1&2, ��K'I L` V Ny 128 y z
Cell#: NA Land Line#: 518-(,S(�- 1�.1 z-n -v
Email: jQ-ah I3I<"Vx�+9cy COM P°m -�
Tee'c n Va-h h cLt ea &1 i�l aa, �,�l�er lr aka�S��s}��- o M o �
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Applicant(if different than above): /�T n� Cl)�
Mailing Address(c/s/z):_111.3-�slay'j e04 �U f1QhC{�,57�✓1yPC3107! U
Cell#: 663-y 9y. 328 Land Line#:
Email:_prkS'S'(Z)CQIneU4. I1e+
❑Proposed Owner ❑ Realtor ❑ Attorney ® Other(explain:45n cF�Pz� �
n
Septic Contractor: 'U S
Mailing Address(c/s/z): a Lower Lba n s/, QU¢ens��ry Ny 1.)80r(
Cell#: Land Line#: SI - -9g-81�y
Email:Jn-�Orc�l 10'Ss A C- eom
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? 3
Year system(s) installed: Tank Size of Septic Tank
Type of Absorption System:
Are all system components wholly within the property boundaries? JK Yes ❑No
Are system plans available? ❑ Yes ❑ No
Does the system(s) serve multiple properties? ❑ Yes No
If yes, describe
Maintenance:
Service agreement?❑ Yes IS No; If yes, business' name
Date of last inspection N/A Date tank last pumped N/AJ]
Frequency of pumping N/A2
List known repairs/replacements,with dates:
Date Type of Repair/Replacement
Operation:
System problems? ❑ Yes No
Sewage odors? ❑ Yes ❑ No
Direct surface discharge(s)? ❑ Yes ❑ No
Back-up of toilets? ❑ Yes ❑ No
Back-up of any other fixtures? (e.g. slow drains) ❑ Yes ❑ No
Seasonal ponding or breakout of leach field? ❑ Yes ❑ No
Property Transfer Packet Revised July 2022
DocuSign Envelope ID:76C2B19D-5lD8-4F86-A8C5-483DB05D1602 -
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 30%of the fee is retained by the Town of
Queensbury.
Signature of property owner or authorized agent:
Affiliation: ®owner 'p agent ❑other:
Peter Kahn
Please print name:
ruby:
Signature: DateP/14/2022 16:51 AM PDT
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
1
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D �' C E E
SEP 14 2022
TOWN OF QUEENSBURY
BUILDING& CODES
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TOWN OF QUFFNSBURY
tS�-GYI�> BUILDING & ZONING DEPAR E O W E
•SEP?AGF DISPOSAL PEPMIT APP I
1. owner' s Name p�p p„ �,,n SEP 14 2022
Address t��- TOMOF QUEENSBURY
��k,� dAA Telephone No.
2. Property locatiori,74D1 61 ►�ch �tQ
3. Name of person-. or. firm responsible for- installing system
JQJ-�y Ell ,.: Telephone No. (pin -46�''�
Address ,
4. 'Number of bedrooms (residential buildings-only) ,
5. Daily flow (�j���� gallons/day
6. Septic tank capacity („X(„ ,� � �.��( gallons
7.• Topography: �fjlat olling:, steep i
% of slope
8. Nature of -soil and depth
9. If. ground water, bedrock or impervious material is apparent at what
depth does it begin? °vfoc-_� ft.
1.0. Percolation test: A is required
B r/ is not required.
C If' required what is the rate minutes/inch
11. Water supply: municipal, well, other 66—
12', Type of system proposed: drywell, the field, ,other
Any contractor,, corporation, individual, etc. engaged in' the construction
of a sanitary sewage disposal system -who -covers the same before inspection,
does not have an approved permit, or varies from the approved application
will be• subject to a-penalty of $250 as -provided •fo . in Section 6.010 of the
Queensbur-y Sanitar-y Sewage Ordinance.
Date_- 911ajk4 ,, zmm
signature • plicant
On sepaate sheet of paper submit a diagram of the proposed septic system
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with all dimensions, including distance from any structure, distance from
. property -line and domestic water supply, etc. Include all dimensions of
the system itself..
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Form 3--82 - -— -
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