PT-0021-2023 Property Transfer Sewage Disposal Information Form
r Date: �JZ3
Town of Queensbury
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.gueensbury.net
Joshua Brown
(Name of Owner/Applicant)
Re: Onsite Wastewater Treatment System Inspection Information Request for:
20 Birch Rd, Lake George 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 1st of the current, or following year (whichever comes first), a map locating the septic
system and payment totaling$2275 ($2000 refundable deposit plus$275 permit fee). The deposit is forfeited
if the owner fails to complete the repairs or installation as stated above..
If you have any questions, please call.
Phone: (518) 761-8256- Email: kated@queensbury.net
Thank you.
Sincerely,
John O'Brien, Director
Bu Vlding and Code Enforcement
Town of Queensbury
Property Transfer Packet Revised July 2022
,- Office Use Only
2 f�
DPermit#: - �
Town oftQuccnsbury JAN 19 2023 Fee:_$ 27S ,00
742 Bay Road,Queensbury,NY 12804
P:518-761-8206 or 518-761-8205 Invoice#:
www.ciueensbury.net TOWN OF QUBFNSBURY
BUILDING& CODES 42D00 �yia0lcy
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 surveyor tax parcel map)
Property address for inspection: 20 Birch Rd, Lake George NY 12845
Tax map number: 289.13-1-36
Property owner: Joshua Brown
Mailing Address (c/s/z): 77 Sarah Jen Dr, Queensbury NY 12804
Cell #: 518-649-2167 Land Line#:
Email:jsbrown@trccompanies.com
Applicant(if different than above):
Mailing Address (c/s/z):
Cell#: Land Line#:
Email:
❑ Proposed Owner ❑ Realtor ❑ Attorney ❑ Other(explain: )
Septic Contractor: Action Septic ` + �i
Mailing Address (c/s/z): O® e��13 �3o4 5 -
D Gleam
Cell#: Land Line#: V a--79.3 -4-/9 q?
Email: Ch(25a.0 A Ur A C011"
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 3 # Bathrooms 2.5 # Kitchens 1 Jacuzzi tub(s)0 Garbage grinder 0
Onsite Wastewater Treatment System:
How many systems are on the property?
Year system(s) installed: Tank 2002 Size of Septic Tank 1000
Type of Absorption System: leech field
Are all system components wholly within the property boundaries? ❑i 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 2019-2020 N/A ❑
Frequency of pumping 6yrs? N/A ❑
List known repairs/replacements, with dates:
Date Type of Repair/Replacement
N/A
Operation:
System problems? ❑ Yes ❑■ No
Sewage odors? ❑ Yes 4 No
Direct surface discharge(s)? ❑ Yes 54 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
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: ❑i owner ❑agent ❑other:
Please print name, Joshua S Brown
1/19/23
Signature: 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
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TOWN OF QUEENSBURY
BUILDING_ b CODE ENFORCEMENT
742 Bay Road
Queensbury NY_1_2804
(518)761-8256 VAN
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SEPTIC DISPOSAL SYSTEM INSPECTI
19 2023
NameF QD$Bll
BUILDilvIG s DODEBRY
Location .
Date )_ - Permit # _C 1
SOIL TYP - an am-Clay-
Results of Percola n Test-
(if applicable) Ra e--Minute/Inch
TYPE OF SYSTEM:
ABSORPTION FIELD:Rare--:'Minute/Inch
Length
Length of each trench
Depth of trenches
Size of stone
SEEPAGE PITS: Numb r-
Size - r ft. ft.
Stone size
PIPING: Size Type
Bldg. to Tank u � 6
Tank to Dist. Box
Dist. Box to Field/P t tl ��}C,r) It3w
Openings Sealed? o Partial
LOCATION/SEPARATI
Foundation to Tank Cyt�eet
Foundation to Absorpt on � eet
Separation of Pits feet
Conforms as per Plot lan �
LOCATION OF SYSTEM ON PROPERTY:
(circle one)
ran Rear - Left Side - Right Side
i e Front - Middle Rear
COMMENTS:
SYSTEM MSROILV:
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Affidavit. -
9 3..2023
STATE OR-TEXAS ).
ss.:. TOWN OF QUEENSSURY
COUNTY.OF �_l LVtS. . ).
BUILDING& GoDES.
I;CRA.IG FELDIVIAN;being first duly sworn;.depose and say as follows:
L :. I am amember:of C&CF�.Real_Esfate Investments LLC.that ispurchasing 20-Birch: .
Road;Town of Queensb ury,Warren County,New Rork 12804: .
. 2: At the time of purchase,I agree to-provide_the Town of Queensbury Xiith a
$2'000.00--as a refundable escrow until the distribution box has.been repaired and a
uccessful On-site Wastewater Treatment Inspection has been co' I ted:by the
- Town,of Queensbury Building-And:Codes Eiifurcement Office.
3.: _. I'agree.that no persoh.shall occupy-this.property until a-successfU On=site..
Wastewater.Treatment Inspection has been.completed:by the Town:of'Queensbury
Building and Codes Enforcement Office.: _
C&CF.Real'Estate Investments LLC . .
Craig Feldman; ber
. Y'.. ND. :BELL.
Subscrib�d and sworn to.before me �+�
a° . SAND.
Public.
this __ ay.of FebrU ,20 * * . -: -STATE OF-TEXAS - .
My
23: .'
Comm.Exp.01-14=25
.. Nofary.ID#:129752141 .
VT 32 JQZQ >:
E � : r ;�TURNLO-1 DITION QPTI4��5 `
:Du to one ofgElie�,condtions�listedrbelow�=,I±am�re �aestin�`-:anyexem��tion�from�tlie�°:
. . Septic>Idspection?Up�a�Pir�opei�.ty Transfer�.by,ti�e To�wn�.of iQneensliury�:�:�-; . .
:= PLEASE CHOOSE.ONLY ONE CONDITION BELOW IF YOU ARE REQUESTING'A WAIVER .. . -
❑ Tlie property to be sold.or transferred Willnot:be:inhabited,andthe 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 Enfo cement:Office stating that the dwelling_will not.be inhabited and.that itwill.be'
deTolished:with no.immediate plans to re'build'or the dwelling will not be inhabited,it will be' .
derndlished'arid rebuilt,in Which case the:affidavit shall be.accompanied by a.site plan;including_
adequate:detail to demonstrate.t lawful OWTS to ether with a check a able too the Town of
:. . .g y
Queensbury in the amount of$2,00.0. Such:funds.will be.held in anon-nferest-bearing escrow account .
and will:be,released :in-the-former case,upon issuance:of a demolitibr peimit`and;in tliie-I tier case;
upon issuance:of a certificate of compliance from the Building and Codes.Enforcainent Office.If the.
Property Transfer ins ection is not:coin leted.within:that 6. six month timeframe ,;
P. tY P .. P ( )..
.:the$2000 will be forfeited.
AADWTS:inspection.was not able to be completed prior to the conveyance of real pioperty.dueto.
inclement weather.In order to qualify.for the exemption,:a notarized affidadit from the new.0 6 erty
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 beheld in-anon-:
interest-bearing escrow account and shall:lie:released.upon the:completion.of a satisfaatory:OWTS
inspection from the:Building and Codes Enforcement Officer If the Property.Transfer'
inspection is no .completed:within.that.6(six).month or June-1st timeframe, the
$2000 will be forfeited..-:.:
0 The„property to be sold or transferred contains,an existing OWTS that does hot.complywith the:
provisions of this article;and the prospective purchasers and/or the'Selle'r.wish to forgo an inspection
m favor of installing an approved OWTS within six months.of the'transfer of property.In order to :
qualify for the.exemption,a notarized affidavitmust be submitted:tci iheBuildirig and'Cod6s =
Enforcement.O.. .ffice 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
thatthe'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 ofcompl_iaace from the Building and Codes
Enforcement Office"it the,Piro er Transfer ins ection.is not tom leted within that 6
P - h' p : P.. . .
. . _ : -(six) month:timefra me, the$2000 will:be forfeited:
IEV 9
A 2.3
023
TOWNl.OF QUEENSBURY
BUILDING&CODES.: :
Property Transfer.Packet. Revised July 2022 -
r
,.
Winter d
Dunng the OWTS inspection,a failure.of the septic system was:determined:Due to w
fgozen conditions,the re air to an existing ow-T. could not occur or.:a new OWTS could not be
P
installed before tl►e conveyance of real property..In ordec.:to:q!-.-Y forthe;exemption;anotarized:
affidavit from the new propertyowner to complete the installation or repair of.the septic system within
a"tx trionths from the date.of the conveyance.of real property,or:June 1,whichever comes first;must be
..
filed'witli tite Btilding and Codes:EnforcementOffice.:A ch.. I. yable to the Town of Queens ury m .
the amount of$Z,000.will be in a non-interest-bearing escrow account and shall be released upon
the coingletion of the repair of installation of a new.septic system and a satisfactory.OWTS:inspectiori
from the Buildingand Codes EnforcementWfice.If.the-Property Transfer inspeetion.is not
cornpletesl:-Withia�thatt 6(six) month or June lst timeframe;-the�200(B.vvill be
forfeited:. -
There is a record of a septic system inspection Upon.pioperty transfer pecmif and inspection completed
El .. d pl ide a copy of this record.:
an passed within,
last three years: ease prow:
PLEASE READ:I�I®TICE TROROUGHI�Y:
Failure to com lete'the inspection,-obtaiii the perinitor complete all repairslinstalIations .
P
identified en'the preceding subsecfions of this section within the_time provided or aaiy subsequent .
deadline established-by-the Building and Codes Enforcement office ' nr the con&esult ions can ed e
moneys field in escrow,and.the.Town may use.such funds.toward a a t g
:by each Such violation of this article. _
ear of submission of a completed application
Inspections,Must:take dace within one(l)y
Inspections:scheduled to take'place.after the year period.will be subject to-submission.
a renewal a lication and payment of the renewal fee.based.on the current fee schedule.
of .PP
K7 K
ONLY SIGN T]H[IS PAGE IF�YOU AI2E OPTING FOR A WAIVER RE
I have read and understand:the:above notice regarding the expectations;andpossible forfeiture :
of imoneys submitted:toahe Town of Queensbury,for an.exemptiori re
quesfic
�.
Pfirit Name:. �� . . ..
Date:
Sign Name;.
Buyer:` .
a2
Print Name:
DDate:
Sign Name:.
RcMscd July2022..
Property.Transfer Packoc