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PT-0016-2022 Property Transfer Sewage Disposal Information Form Town of eensb Date: 1/17/2023 2 ury 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.gueensbury.net Jane W. Mann Irrevocible Trust (Name of Owner/Applicant) Re: Onsite Wastewater Treatment System Inspection Information Request for: 174 Lake Parkway, Queensbury, NY 12845 (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 11t 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 ro John O'Brien, Director BU9ding and Code Enforcement Town of Queensbury Property Transfer Packet Revised July 2022 Office Use Only Permit#: P%'oal b TOMofQirccnsbu�} Fee: 742 Bay Road,Queensbury,NY 12804 P:518-761-8206 or 518-761-8205 Invoice#: www.aueensbury.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: 174 Lake Parkway, Queensbury, NY 12845 Tax map number: 226.15-1-1 Property owner: Jane W Mann IrrevocableT rust,Michael S. Mann,Trustee O Mailing Address (c/s/z): 3127 Enclave Ct., Pikesville, MD 21208 Z Cell #: 410-241-8877 Land Line#: oo mmann d @ hotmail.com Email: ) Q°rnjr-:�a rn �t T S Ma nn,ann, Trustee Applicant(if different than above): Michael � Mailing Address(c/s/z): 3127 Enclave Ct., Pikesville, MD 21208 Cell#: 410-241-8877 _ Land Line#: Email: mmannjd@hotmaii.com ❑Proposed Owner ❑ Realtor ❑ Attorney Other (explain:Trustee. ) Septic Contractor: IBS Mailing Address (c/s/z): 2 Lower Warren St, Queensbury, NY 12804 Cell #: Land dine#. (518) 798-8194 Email: info @ ibsseptic.com Reason for Inspection Request: ❑On the market ❑ Future listing ❑Sale Pending A Deed Transfer ❑Other: Property Transfer Packet Revised July 2022 HOUSEHOLD INFORMATION "PLEASE SEE SEPARATE PAGE FOR EXEMPTIONS" # Bedrooms 4 # Bathrooms 5 # Kitchens 1 Jacuzzi tub(s) Garbage grinder 1 Onsite Wastewater Treatment System: How many systems are on the property? 1 Year system(s) installed: Tank 2004 Size of Septic Tank l000? Type of Absorption System: Are all 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 ❑■ No; If yes, business' name Date of last inspection N/A ■❑ - Date tank last pumped August 2021 N/A❑ Frequency of pumping every 1-2 yrs. N/A❑ 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 p 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 2Q2 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 ❑agent ■❑other: Trustee Please print name: Michael Mann Signature: Date: 1/17/2023 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 Septic Inspection Report Office No.(518)761-8256 Date Inspection request received: I . Queensbury Building&Code Enforcement Arrive: amp D part: amlpm 742 Bay Rd.,Queensbury,NY 12804 Inspectors Initials. ��� ZA NAME: t �J,J PERMIT NO.: ✓ LOCATION: INSPECT ON: 1 RECHECK: Comments and/or diagram Soil T e: �LOam/Clay Type of Water: Municipal/Well Water Waterline separation distance ft. Well separation distance ft. Other wells: ft. Absorption Field: Total length ft. Length of each trench (° ft. Depth of trenches --LAC - "�; ft. Size of Stone Seepage Pits: Number Size: x Stone Size: Piping Si7,e;, Type Building to tank Tank to Distribution••ox Distribution Box"Fi d/Pit Opening Seale - /Partial End Caps Location/Separations Foundation to tank Foundation to absorption7/ft. f Separation of Pits ft. Conforms as per Plot Plan Y N ��'� J Engineer Report and As-Built Y N Location of System on Property: ={ G G� Front Rear Left Side Right Si v ti Middle Front Middle Rear System Use Statu . Approved Partial Approved and needs to be re-inspected,please call the Building&Codes Office Disapproved Last revised 1/6/05 COMMONWEALTH ELECTRICAL INSPECTION SERVICE, INC. Main office 176 Doe Run Road - Manheitn, PA 17545 MUNICIPAL CERTIFICATE - ELECTRICAL APPROVAL 00` "00 IN Permit No. .......................................Cert. 0 9 0 18 0 Cut-in Card No. Owner........................... .... :.. .... :................................................................................................ ...... ............... . Location ....../................................... ................ ................................................................................................. InstallationConsistingof....... :.................... .. . :.. .. ... .. ...` ... . ......................:......................... ... .\ •...............\\.•1......../...............\........••...,.............,....................................................••.................................................... •........\....................•...../....,......,.................................................................................................. .•.\•........1............,.....• InstalledBy.........................................................:.................................Lic. No. .................................................. The conditions following governed the issuance of this certificate, and any certificate previously issued is cancelled: - This certificate only covers the electrical equipment and installation conditions as of date. Upon the introduction of additional equipment or alterations,.application shall be promptly made for inspection. Inspectors of this Company shall have -the privilege_ of makin pections at any time, and if its rules are violated, the Company shall have the right to re a thi 'ficat . <00 Date.................................................. INSPECTOR .. .0.... ...... ....,.................................. .. �......................... Memher N_FP_A_. I_A_K-L • 169 Haviland Road Queensbury,NY 12804 . Hutchins Engineering Phone: (518)745-0307 Fax: (518)745-0308 -pc -A) RECEIVED - JUN 2 4 2005 June 24, 2005 TOWN OF QUEENSBURY Mr. Michael Gargiulo ` BUILDING AND CODE Dormers-Golden Properties, LLC .16 Harold Harris Road Queensbury, NY- 12804 Reference: Assembly Point Residence Dear Mr. Gargiulo: At your request, we have-prepared a biomat (Eljen) absorption system layout intended to be equivalent to the-bed absorption system with pressure distribution you had - previously.proposed, as shown on approved design prepared by DL Dickenson Associates, dated April 14, 2004.` Attached are two sketch drawings showing system components and installation details.. ' These details have been prepared as an equivalent field to that previously approved and have been prepared without co nducting-a.detailed field evaluation of site . conditions.: Please contact me if you require additional information. Best Regards, G: Thomas Hutchins, P.E. , G.Thomas Hutchins,P.E.