PT-0066-2023 property Transfer Sewage Disposal.Information Form:
pate:
Town of
Q aeensbu
_
742 Bay Road,Queensbury;-NY 12804.
P:518-761-8256 www:gueensburv.net
(Name:of Owner/Applicant)
Re: Cinsiite Wastewater Treatment.System Inspection Information Request for:
:(Site.Address for.Inspectiori)
Thank you for.requesting an inspection.16r.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 d0
the best job possible by.providing someadvanced.information about the site: Priorto our inspect'ion;.we,re' t
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 feels) and dociamehtation, prior.toscheduling.an=inspection: .
Please note the Town,of Queensbury's'feefor this service is$275 ,Be advised:that'all fees must be paid prior to.
schedulins.the inspection: We require 48 hours notification�priorao'scheduling'the inspection:
If the
purchaser requesting an ek Mptioni,please submit this:application,.a long.With a notarized letter stating
the�septic.-system will be inspected-or repaired/replaced.within 6:months- the .date.of the Property
Conveyance.or June.V'of the current,-or followirig year(whichever;comes-first),-a .map locatirig.the.septic.
:system and payment:'totaling:$2275 ($2660 refundable deposit plus.$275'permit fee): The deposit is forfeited• : .
ifahe owner fails.to complete the 'repairs or installation as.stated above.,
1f.you have any questions, please-call..
Phone:-(518) 76178256 Email: kated@queensbury.net
Thank you.
Sincerely;
John.O'Brieni Director
_B i ding and Code,Enforcement
Town of Queensbury
-Property Transfer Packet Revised February 2022.
Office Use.Only .
Permit#• �'T- r 202
TaNm of Quccnsbuq Fee:
742 Bay Roaa,,queensbury;NY 12804
P:518-761-8206,or518-7614205 Invoice#:
www:aueensbutV.net
SEWAGE DISPOSAL.SYSTEM:INSPECTION INFORMATION
Individual Residential Wastewater Treatment System
CONTACT.INFORMATION.(please print legibly'or type and include an ernallUaddress).
Property-and Owner Information: (Please attach property survey or tax parcel map)
�-2 . .
Property address for inspection: X� I �e'��`S '�'S . 7 ' f9��f
:.
-Tax map number: - ..Z
Property owner: .: -Lp_ - •tee k: Y( � -$
Mailing Address (c/s/z): :.��'1-�- . .• �,`.w�ccr.�: Rd. . : Q-� . ar�. .0-., ►ZIP f
Cell#: .�$ �-(uC �..�"e 1.� . Land Line'M".
Email:'
C IE0VI
Applicant(if different
than above):
Mailing Address(c/s/z): IIFEB 2 f
fFi : .�
Cell.#: La;nd Line#: d.UUi�ICQFUHHEIf}lMlil,
• �.lJhlliyfi9J���t�
Email:
M Proposed-Owner ,.C Realtor E] Attorney Other (.explain: ) .
Septic Contractor: li
Mailing Address (c/s/z): 7• (�
Email:.. .
Reason for Inspection Request-
0 On the market Future listing EI Sale Pending Deed Transfer E]Other.:.
Property Transfer Packet Revised February 2022
HOUSEHOLD INFORMATION
*PLEASE SEE SEPARATE PAGE FOR EXEMPTIONS**
# Bedrooms. #Bathrooms I #,Kitchens ( Jacuzzi tub(s) . Garbage grinder:.
Onsite Wastewater Treatment System:
How many systems are on the-property? 1.
Year systems) installed: "rank": Size of Septic Tank
Type of Absorption System:
Are all system components.wholly within the prop erty•boundaries?: es. . ❑ No
Are system plans available? El Yes . No.
Does the systems) serve multiple.properties? El Yes No.
If yes,.describe..
Maintenance:,.
Service agreement?•p Yes CX No;. If yes, busines'name
Date of last.inspection - .N%A16 Date tank last pumped: N%A�'
Frequency of pumping : N/A 19
List known repairs/replacements, with dates:
Date. TVpe of Repair/Replacement
Operation:
System problems? ❑ Yes -.S No
Sewage odors? p Yes .- No.
Direct surface:& harge(s)? p Yes No-
Back-Up of toilets? ❑ Yes . E] No .
Back-up.of any other.fixtures?.(e:g: slow.drains) El Yes 15-No
Seasonal ponding or breakout of leach field? ❑ Yes [ -No
Property Transfer Packet -Revised February 2022
Statement of Acceptance of Conditions:
I agree to:
• -Ensure that the.sepbc.tank(s), distribution box (es), and/or seepage pit(s), if any,'will
be.uncovered priorto the requested inspection time;
• Have a seetage hauler on'site (to pump the tank after*the inspector: verifies flow
from fixtures);
➢ Tank must:be pumped in presence of inspector
e 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 l acknowledge
the following.
After. l year from-date.of submission and there is no activity on this permit, the permit will.
expire and will be subject to-subrriission 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 20% of the fee is retained by the Town of
Queensbury.
-Signature of property owner or authorized agent:
Affiliation: �k6wner p agent - p other:
Please print name: (L44-a t 1
Signature: Date: '
Prior to schedulina with.the Town of Queensbury, you MUST:
L 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 February 2022'
EXEMPTION CONDITION OPTIONS
Due to one of the conditions.listed below, I am requesting an e'xemption.from the: .
Septic Insp.eetion:Upon Property Transfer by the.Town.of'Queensbury: .
PLEASE=CHOOSE ONLY ONE CONDITION BELOW IF YOU ARE.REQUESTING.A WAIVER
0 The,property to be sold or transferred will not,be inhabited,;and the: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 Enforcement Office stating that the dwelling will not be inhabited-and that it will be:
-demolished with.no immediate.plans to rebuild or-the dwelling will not be inhabited,.it will be
demolished and rebuilt;-iii which"case_the affidavit shall be:accompanied by a site plan;including.
adequate detail to.demonstraie a lawful OWTS;.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, in-the former case,upon issuance of a demolition.permit and; in the:latter case,. .
upon issuance of a certificate of compliance from the Building and Codes Enforcement.Office: If the
Property Transfer inspection is not completed.wit .i that 6;(sig) month timeframe,
the $2000 will be forfeited.
An OWTS inspection.was not able,to be-completed prior to the conveyance of real property due.to
inclement weather. n.order to'qualify for.the exe p#on,a notarized affidavit.:from the new property.
owner-to complete the requisite.OWTS inspection within six month's of the date;of the=c0nveyance of
real property, or-June:l,.whichever comes first;must be filedwith the-Building and Codes Enforcement-
Office. A check payable to the.Town of Queensbury in the amount of$2,000 will be held in anon-
interest-bearing escrow.account and shall be released uponthe,completion of a satisfactory OWTS
inspection from:the Building and Codes Enforcement Off ce. If:the Property Transfer --
inspection is not completed within that 6 (sig) month or June 1st timeframe, the
$2000"will be forfeited.
The property to be sold or transferred contains an existing QWTS that does not comply with the
provisions of this article,.and.the prospective purchasers.and/or the Seller wish:to forgo an inspection .
in favor of installing an approved-OWTS within"six months"of the transfer of property: In order to
qualify,for-the exemption; a notarized affidavit must be submitted to the Building and Codes
Enforcement Office 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
that,the 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"of compliance from.the Building and Codes .
Enforcement Office: If the.Property Transfer:inspection is not completed within that 6
'(six) month timeframe, the $2000 will:be forfeited.
Property Transfer Packet Revised February 2022.
r During.the OWTS inspection,a failure-of the septic system was determined.Due to winter and
frozen conditions;.the repair to an existing ONUS could not occur or a new ONUS.could not-be
installed before the conveyance of real.property. In order.to-gualify for.the exemption,-a-notarized
affidavit from the new property owner to complete the installation or repair of the septic system within.
six months fro_m.the date of the conveyance of real property;or Tune 1,whichever comes first,mustbe
filed with the Building and Codes Enforcement Office.:A check payable to the Town of Queensbury in . .
the amount of$2;000 will be held in a non=interest-bearing escrow account and shall be released upon
the completion of the repair or imtallation of a new septic system and a satisfactory OWTS.inspection
., . : -from the Building and Codes Enforcement.Office. If the..Property Transfer-inspection_is not
-completed within that 6 (94) month or.June Ist•timeframe;-the$2000 WM be
forfeited:
There is,a reoord.of a septic system inspection upon property transfer permit and inspection completed
and passed within the last three years.-Please provide a:copy.of this record-.-.
PLEASE READ NOTICE THOROUGHLY:
Failure to complete the inspection-.obtain the-permit or-eomplete:alfrepairs%installations
identified-in.the:preceding subsections of this section within:the.time provided or any subsequent
deadline'established-by the Building and Codes Enforcement-.Office will'result-in-forfeit ume-of the
= moneys held in escrow, and,the Town-may use such.funds toward abating the conditions caused
by each such.violation of this article:
Inspections must-take place-within one (1).year of submission Hof a completed.application..
Inspections scheduled to:take place.after'the one'year.•period;willbe subject-to.submission
of,a renewal application and:payment of the-renewal fee based on the current fee schedule.
ONLY SIGN THIS PAGE-IF YOU ARKOPTING FORA WAIVER REQUEST!!***
I have:read and understand the above notice regarding the.expectations and possible forfeiture
of moneys submitted to.the Town of Qiieensbury for an exemption request.
Seller:
Print Name:
Sign Name: . Date:
Bum
Print Name: ..
Sign-Name: Date:
•Property Transfer Packet Revised February 2022'
Daniel Flores
March 13, 2023
195 Haviland Road D IE 9 E
Queensbury NY 12804
MAR 17 2023
r
TOWN OF QUEENSBURY
BUILDING&CODES
To whom it may concern,
A new code compliant septic system will be installed at 13 East Road by IBS Sewer&Drain and inspected
by the Town of Queensbury and completed on or before June 1st of 2023.
Dan Flores
State of New Yo t
County of . Y�/(\�
On tha •- day of Ak4o me ap jy Came " ` (/y]�• .M
to the P@=njXy known.and known to he the IndMduals descehad hi Who executed tho
foregoing In i and duty nowtedg t ha/1-she executed the Same.
NOTARY PUBLIC
NOTARYPUBLIC
STATE OF NEW YORK
WASHINGTON COUNTY
Reg. No. 01 DOO I 702ad
COMM. EXP. 07/02/
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