PT-0198-2023 h
Property Transfer Sewage Disposal Information Form
Date:
Town of Queensbury
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.gueehsbury.net
V-1
CL t �-\ U1 l/L��CJyi
(Name of Owner/Applicant)
Re: Onsite Wastewater Treatment S stem Inspection Information Request for:
�'CP 4M
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 V of the current, or following year (whichever comes first), a map locating the septic
system and payment totaling$2275 ($2000 refundable deposit plus$275 permit fee). The deposit is forfeited
if the owner fails to complete the repairs or installation as stated above.
If you have any questions, please call.
Phone: (518) 761-8256 Email: kated@queensbury.net
Thank you.
Sincerely,
1
John O'Brien, Director
1369ding and Code Enforcement
Town of Queensbury
Property Transfer Packet Revised July 2022
Office Use Only
�GL!
Permit#:
Town ofQvcnsbun• ] A f_ r� Fee:_$
742 Bay Road,Queensbury,NY 12804 �/ (� / I
P:518-761-8206 or 518-761-8205 Invoice#: `�05�
www.gueensbury.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: 1 �� Yee cad` I � tW
Tax map number: ?Cl j I -1 '-a 3
Property owner: I j`I CS C I �J D !1 G: LA
Mailing Address (c/s/z): S�&Q
Cell #: 6-f�g'Ql�C Land Line#:
Email: A 0�5`c9vl Re CJ61S cc�L
Applicant (if different than above):
Mailing Address (c/s/z): ►-1-
Lam ; E35
Cell #: Land Line#: �� � �-
Email: ): LAPR 2 8 2(023
❑ Proposed Owner ❑ Realtor ❑ Attorney ❑ Other (explain: MAIM n,
® Septic Contractor: id
Mailing Address (c/s/z):
Cell #: Land Line#:
Email:
Reason for Inspection Request:
On the market ❑ Future listing dale Pending ❑ Deed Transfer ❑Other:
Property Transfer Packet Revised July 2022
HOUSEHOLD INFORMATION
"PLEASE SEE SEPARATE PAGE FOR EXEMPTIONS"
# Bedrooms a # Bathrooms YC3- # Kitchens 1 Jacuzzi tub(s) Garbage grinder X
Onsite Wastewater Treatment System: ��
How many systems are on the property? l
o Year system(s) installed: Tank Size of Septic Tank Type of Absorption System:
Are all system components wholly within the property boundaries? MYes ❑ No
Are system plans available? ❑ Yes ❑ No
Does the system(s) serve multiple properties? ❑ Yes No
If yes, describe ):
Maintenance:
Service agreement? ❑ Yes 5Z No; If yes, business' name CR
Date of last inspection N/A ❑ Date tank last pumped LM N/A ❑
Frequency of pumping N/A ❑ e0,0 V,� QU-) vczp's
List known repairs/replacements, with dates:
Date Type of Repair/Replacement
-Z)P@
Operation:
System problems? ❑ Yes F�<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 IQ-'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: Owner ❑agent ❑other:
Please print name:
Signature: t Date: /QD-7;2
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
iAi—
Septic Inspection Report
3(o1-352�
Omce No.(518)761-8256 Date Ins on request received:
Queensbury Building&Code Enforcement Arrive: am/pm Depart: am/pm
742 Bay Rd.,Queensbury, NY 12804 . Inspector's Initials: 10k
NAME: PERMIT NO.: G 7— 7
LOCATION: INSPECT ON: MID
REOiECK:
Comments and/or diagram
Soil T Sa Cla
Type of Water: Municipal
Waterline separation distance 3 Gy�3
ft.
Well separation distance Aw ft.
Outer wells: ft,
Absorption Field: Total lengthft,
LengM of each trench ft,
DePM of trenches ft,
Size of Stone 2 evC
Pits: .Number r �
x
Stone Size:
Piping Size De
Bu(IdIna to tank `•
Tank to Distribution Box Y Aope- Alec
Box to f Pit
Ovensa Se
0 ni Sealed: N N-1 Partial
End Ca
In Outlet Pipes&Baffles Y N
Location rations
Foundation to tank ft.
Foundation to absorution ft.
Separation of Pits ft. t
Conforms as per Plot Plan Y N
E ineer Report and As-Built Y N
Location of System on Property:
Front 0 Left Side Right Side
Middle Front Middle Rear
System Use Status:
Approved
Partial Approved and needs to be re-Inspected, please call the Building&Codes Office
Disapproved
Last revised 021006
Last revised 116105
' 1
Septic Inspection Report .
Office No.(518)761-8256 Date In request received:
Queensbury Building&Code Enforcement Arrive: t am/ Depart: am/pm
742 Bay Rd.,Queensbury, NY 12804 Inspector's Initials:
NAME: PERMIT NO.:
LOCATION: INSPECT ON:
RECHECK:
Comments and/or diagram
Soil : Sand Loam Clay
Type of Water: Municipal Well Water .
Waterline separation distance ft.
Well separation distance ft.
Other wells: ft.
Absorption Field: Total lengthft.
Laxith of each trench ft. ok
Depth of trenches ft.
Size of Stone
Seepm Pits: Number,
Size: x
Stone Size:
Piping Size Type
Building to tank
Tank to Distribution Box
Distribution Box to Field Pit.
Opening Sealed: Y NI Partial
End Ca
In Outlet Pipes&Baffles —Y—N:]
Location Separations
Foundation to tank ft.
Foundation to absorption ft.
Separation of Pits ft. Sea �
Conforms as r Plot Plan Y N
Engineer Report and As-Built 1QY N
Location of System on Property: ,� Tr Gam,/
Front Rear Left Side Right Side
Middle Front Middle Rear
JQ ��
Approved
Partial Approved and needs to be re-inspected,please call the Building&Codes Office
Disapproved
Last revised 021006
Last revised 1/6/05
iI1../.IIII.. ............I....I....................................i /L._I.................r
��j OFFICE USE ONLY ' '
TAX MAPS 0�� PERMIT N0. RMIT FEE S REC:�'DIED;
1
APPROVALS: ZONING TOWN CLERK '
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APPLICATION FOR SEPTIC DISPOSAL SYSTEM PERMIT,rUILDING AND CODE
A PERMIT MUST BE OBTAINED BEFORE WORK BEGINS.APPLICATION IS SUBJECT TO REVIEW BEFORE ISSUANCE OF A VALID
PERMIT.
OWNER,�>�-2 J e i1 7e�\n S Q N INSTALLER: 26e W AJ M�-. 1V\0C1
�2 Win z��-
ADDRESS: CO.tef%S l l S,/u y It e o I ADDRESS: V'i
47 [=oe i- ^r%^, NY
PHONE NOS. El V 7 Z^ Z PHONE NOS. 5-1 y' 2SO 1^ S yy
LOCATION OF INSTALLATION: k j T 6 LQAJ k��•. N y
NO.OF -- RESID"E INFORMATION:
YEAR BUILT X COMPUTATIONS . TOTAL DAILY FLOW
BEDROOMS _ _ _ GARBAQi:GRINDE�
1980 or older »» X »i so pa0on per bedroom P »■» » pwO INSTALLED? ba_,
»»»�1g81-1991 »»» X 130 gallon par bedroom ■ SPA OR HOT TUB
Pim-present» »»» X 110 gallon per bedroom» . »» � �»_ »»»» INSTALLED? Ai y
PARCEL INFORMATION: »�� �. I •���� _��_ '
✓ ,TOPOGRAPHY: FLAT ROLLINd.4 STEEP SLOPE %SLOPE
✓ SOl NAME TURF:SAND_, LOAM CLAY OTHER Cy b(�
✓ ,GROUNDWATER:N°AT WHAT DEPTH? BEDROCKIIMPERVIOUS MATERIAL, AT e
WHAT DEPTH?
✓ DOMESTIC WATER SUPLY: MUNICIPAL.., WELLA
(IF WELL:WATER SUPPLY FROM ANY SEPTIC-SYSTEM ABSORPTION IS-)d 0 FT`)
✓ PERCOLATION TEST: RATE IS MIINUTE PER INCH(TEST TO BE
COMPLETED BY A LICENSED PROFESSIONAL ENGINEER OR ARCHITECT)
PROPOSED SYSTEM FOR NEW CONSTRUCTION: All Individual sewage disposal systems must be designed by
a licensed professional engineer or architect(unless installed in a Planning Board approved subdivision).Add 250
gallons to the size of the septic tank and leach field for each garbage grinder,spa or whirlpool tub:,
✓ SEPTIC TANK: 1000 GALLON(MIN. SIZE IS 1,000 GAL.) TILE FIELD: EACH TRENCH FT.
✓ TOTAL SYSTEM,LENGTH: FT. SEEPAGE PIT(SI:HOW MANY?'
✓ SIZE OF EACH aQ --FT.X - FT.
✓ SIZE OF STONE TQ BE USED:# Z /DEPTH OR THICKNESS IZ FT.
✓ QED SYSTEM SIZE: �0 X
• � 1
✓ ALTERNA VE S TEM: LENGTH ANDJOR SIZE
✓ HOLDING TA SYSTEM:(it required)NO.OF TANKS: /SIZE OF EACH
✓ GALLONS. OTA CAPACITY.,-GAL.
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NOTE: ALARM SYSTEM AND ASSOCIATED ELECTRICAL WORK MUST BE INSPECTED BY A TOWN
APPROVED ELECTRICAL INSPECTION AGENCY. PLEASE REVIEW LIST PROVIDED. '
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For your protection,please note that pursuant to Section 136.29 of the Code of the Town of Queensbury,any
permit or approal granted which is based upon or Is granted in reliance upon any material misrepresentation or
failure to m a m edal fact or circumstance known by:or on behalf of an applicant,shall be voids
I have read e r, ulations with.respect to this application and
agree to a I these and all requirements of the Town of QUESTIONS? CALL T61.8256 OR EMAIL
Queens S nary Sewage Disposal Ordinance. y�aea®oueensburv:net
VISIT OUR WESSITE FOR MORE INFORMATION
www:ampaburv.net
Siy o r n Responsible Date
Town of Queensbury•Community Development Office• 742 Bay Road, Queensbury,NY 12804
PROPERTY TRANSFER SEWAGE DISPOSAL INSPECTION LETTER
V Satisfactory Compliance Notice
Town of Qyccnsbury
Building&Codes Enforcement
742 Bay Road,Queensbury, NY 12804-5902
P: 518-761-8256 www.gueensbury.net
Date: 9 May 2023
To: Vicki Johnson
(Applicant)
Re: System Inspection Site Report for:
96 Hall Rd, Town of Queensbury, NY
(Site Address)
As requested, the Town of Queensbury's Building and Code Enforcement Department
has made an inspection of the wastewater system components serving the property referenced
above. All system components have been found, and are noted in the System Inspections
Findings Worksheet.
Inspector's observations:
The system appears to have functioned adequately under past and present loading.
There can be no assurance or guarantee of future performance for any period of time.
Numerous factors, such as household water usage, leaking toilets, soil characteristics and
seasonal ground water table fluctuation, as well as owner failure to manage and maintain the
system, will affect its performance.
This approval is valid for 3 years from5/9/2023, the date of the inspection.
Sincerely,
A
John O'Brien, Director
Budding & Codes Enforcement
Town of Queensbury
/kd Revised March 2022
SITE PLAN
SCALE: 1'-2W
MAP REFERENCES
APPROXIMATE PROPERTY LINES AND BWLDING
LOCATIONS TAKEN FROM:
WZWff_j: 'MAP OF LANDS OF USA M.
JACKOSKI' PREPARED BY: JOTREY Q MARTIN. PLS,
SOUTH GLENS FALLS, NY; LAST REVISED 2/17/00.
KMBQM-Z- 'SEPTIC SYSTEM a DETAILS'
289.11-1-23 -0198-2�23
PREPARED FOR DONALD & SANDRA KRUGER, BY
VALUAM F- MONTGOMERY, JR, PE; DATED 1/3/03;
Johnson, Vicid
*MAP
FROW. OF A SURVEY OF A PARCEL OF LAND
96 Hall Rd
PREPARED FOR LEONARD H. AND ROSE P.
Property Transfer -sale pending
17B RI ARD W. �"�. U.S. DATED
ADDITIONAL LOCATIONS PREPARED BY NUTC HNS
ENGINEERING, JULY 2006.
ALIU49M OF TINS DOCINElR EXCEPT BY A UCEN5ii1 PRWESSOOIK
O
Issum FOR APPROVAL
8/15/2006
No-
Revisions
Dote
WASTEWATER SITE PLAN
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