PT-0262-2023 Property Transfer Sewage Disposal Information Form
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Town of Queensbury f MAY � � G�';'. � Date:�.
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742 Bay Road,Queensbury,NY 12804 ==R'
P:518-761-8256 www.gueensbury.net (C-1�,'t 'r ? y
(Name of Owner/Applicant)
Re: Onsite Wastewater Treatment System Inspection Information Request for:
E5 2)uQQ,t V Ply a. LAU PmC9 R-. gA -
(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 o.r repaired/replaced within 6 months from the date of the Property
Conveyance or June 15t of the current) or following year (whichever comes first), a map locating the septic
system and payment totaling$2275 ($2000 refundable deposit plus$275 permit fee). The deposit is forfeited
if the owner fails to complete the repairs or installation as stated above.
If you have any questions, please call.
Phone: (518) 761-8:.1.56 Email: kated@queensbury.net
Thank you.
Sincerely,
John O'Brien, Director
Building and Code Enforcement
Town of Queensbury
i
Property Transfer Packet Revised July 2022
F
,r - Office Use Only
Permit#:Fee:
—7 ( _
Tm a£C,Ucen.sbu n• �. _$ ( ✓'• dv
742 Bay Road,Queensbury,NY 12804
P:518-761-8206 or 518-761-8205 Invoice#: co 2-)3
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: o25_ '5 l,c1w van r,
Tax map number:
Property owner:�(i<_l�leAQL, A—ffrec�
Mailing Address (c/s/z): cum- O-S'
Cell #: 5\Q. 4a5 -keo3(p Lend Line#: P/A-
Email:" VMcy O t a- U 46o C&-.-N
Applicant (if different than above):
Mailing Address (c/s/z):
Cell#: Land Line#:
Email:
❑ Proposed Owner ❑ Realtor ❑, Attorney ❑ Other (explain: )
Septic Contractor:
Mailing Address (c/s/z):
Cell #: Land Line#:
Email:
Reason for Inspection Request:
❑ On the market ❑ Future listing ❑Sale Pending Deed Transfer ❑ Other:
Property Transfer Packet Revised July 2022
HOUSEHOLD INFORMATION
**PLEASE.3EE SEPARATE PAGE FOR EXEMPTIONS**
# Bedrooms , # Bathrooms _ # Kitchens I Jacuzzi tub(s) Garbage grinder
Onsite Wastewater Treatment System:
How many systems are on the property?
Years stems installed: Tank) Size of Septic Tank ��
Y ( ) �—� p U �1
Type of Absorption System: J�'f C_
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 U(No; If yes, business' name
Date of last inspection N/A Date tank last pumped N/A ❑
Frequency of pumping N/A
List known repairs/replacements, with dates:
Date Type of Repair/Replacement
Operation:
System problems? ❑ Yes No
Sewage odors? ❑ Yes ( I 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? El Yes No
Property Transfer Packet Revised July 2022
Statement of Acceptance of Conditions:
I agree to:
• Ensure that the septic ta.1-ik(s), distribution box (es), and/or seepage pit(s), if any, will
be uncovered prior to the requested inspection time;
• Have a septage hauler ors 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: 0-0-W n e r ❑ agent" ❑ other:
Please print name: 21MA0
Signature: �0 � -� 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 leati.h field if there is no d-box.
Property Transfer Packet Revised July 2022
Septic Inspection Report
Office No. (518)761-8256 Date Inspection) quest received:
Queensbury'Building&Code Enforcement Arrive: 4 %S am/ � epart: am/pm
742 Bay Rd., Queensbury, NY 12804 Inspector's Initials:
NAME: a PERMIT NO.:
LOCATION: INSPECT ON:
RECHECK:
Comments and/or diagram
Soil Type.4Sqng IC
Type of : Munici I Well Wat
Waterline separation dista ft.
Well separation distance ft.
Other wells: ft.
Absorption Field: Total length ft.
Length of each trench ft.
Depth of trenches
Size of Stone
Seepage Pits: Number
Size: x
Stone Size:
Piping Slzq1 K Tpe
Building to tank �f 115,40 40
Tank to Distribution Box er
Distribution Box 'eld Pit
Opening Sealed: N Partial
End Cap Al
Inlet/Outlet Pipes&Baffles Y N
Location Separations
Foundation to tank ft.
Foundation to absorption ft.
Separation of Pits ft.
Conforms as per Plot Plan Y N
E ineer Report and As-Built Y N
Location of Syst Property:
Front Rear Left Side Right Side
Middle Fron .Middle Rear
stem Use to s:
Approved
Partial Approved and needs to be re-inspected, please call the Building &Codes Office
Disapproved
Last revised 021006
Last revised 1/6/05
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OFFICE USE ONLY ' r ;
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TAX MAP NO. PERMIT NO. ' PERMIT FEE
APPROVALS: ZONING TOWN CLERK SEP 2
/ 2006
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APPLICATION FOR SEPTIC DISPOSAL SYSTEM PERMITP
A PERMIT MUST BE OBTAINED BEFORE WORK BEGINS.APPLICATION IS SUBJECT TO REVIEW BEFORE ISSUANCE OF A VALID y
PERMIT. c J / J
OWNER:Ad� j/I IG IJ �L�A Y�CJl 1 INSTALLER:
ADDRESS: St,{ I I I UG�/7 ADDRESS:
PHONE NOS. q� �g PHONE NOS. '
LOCATION OF INSTALLATION: c_x-f I I ( &q13
• ........................
O••OF• ..t" RESIDENCE INFORMATION:
YEAR BUILT» -. .X COMPUTATION............ .TOTAL DAILY FLOW
»r.r.•.,r.rr
_ BEDROOMS (( GARBAGE GRINDER
»1980 or older »rr...........». •»....._» X »150 gallon per bedroom » ........ " ...»•••»••..»».......................rr.r. I INSTALLED?
»..... ......-...... ... {
1981 -1991 : X 130 gallon per bedroom = i SPA OR HOT TUB
»1992....present,.. ...r...... ....._......»r.•..X.........110 gallon per bedroom:.......=_r......, , ..... '. w�.........r.� INSTALLED?
PARCEL INFORMATION:
✓ TOPOGRAPHY: F R I / °OLL NG STEEP SLOPE J°SLOPE
✓ SOIL NATURE: SAND LOAM CLAY OTHER
✓ GROUNDWATER: AT WHAT DEPTH? BEDROCK/IMPERVIOUS MATERIAL: AT
WHAT DEPTH?_-,94V
✓ DOMESTIC WATER SUPLY: MUNICIPAL WELLZ
(IF WELL:WATER SUPPLY FROM ANY SEPTIC-SYSTEM ABSORPTION IS � ��' FT. )
✓ PERCOLATION TEST; RATE I ZPER MIINUTE PER INCH (TEST TO BE
COMPLETED BY A LICENSED PROFESSIONAL ENGINEER OR ARC TECT)
PROPOSED SYSTEM FOR NEW C.ONSTRUaION: All incjiA6- d] age dis sal 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:,
Co
✓ SEPTIC TANK: 2-_ O GALLON (MIN. SIZE IS 1,000 GAL.) TILE FIELD: EACH TRENCH .-
✓ TOTAL SYSTEM LENGTH:AFT. SEEPAGE PIT(S): HOW MANY?
✓ SIZE OF EACH G FT, X <�1 c FT. \ .
✓ SIZE OF STONE TO BE USED: #_2--J DEPTH OR THICKNESS)-i FT.
✓ BED SYSTEM SIZE: X
ALTERNATIVE SYSTEM: .; O Q -�-- LENGTH ANDJOR SIZE
✓ HOLDING TANK SYSTEM:(If required) NO. OF TANKS: . /SIZE OF EACH
✓ GALLONS.!TOTAL CAPACITY. GAL.
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NOTE: ALARM SYSTEM AND ASSOCIATED ELECTRICAL WORK MUST BE INSPECTED BY A,TOWN
�11!
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 approval granted which is based upon or is granted in reliance upon any material misrepresentation or
failure to make a material fact or circumstance known by:or on behalf of an applicant, shall be void',
I have read the regulations with respect to this application and
agree to abide by these and all requirements of the Town of QUESTIONS? CALL 761-8256 OR EMAIL
Queensbury Sanitary Sewage Disposal Ordinance. codes®aueensburv-net
I VISIT OUR WEBSITE FOR MORE-INFORMATION
www:auee.nsbury.net
ature of son esponsible 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: 1 June 2023
To: Pamela McFerran
(Applicant)
Re: System Inspection Site Report for:
25 Sullivan 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 froml June 2023, the date of the inspection.
Sincerely,
A
John O'Brien, Director
Budding & Codes Enforcement
Town of Queensbury
/kd Revised March 2022
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ONLY AN AUTHORIZED. INDEPENDENT BUILDER APPROVED BY NORTH-
ERN DEEM & BUILDING ASSOCIATES LTD. is P9mrrrED TO USE
THESE DR0111011INGS• NORTHERN DESIGN & BUILDING ASSOCIATES
COPVRISINTED DESIGNS ARE PROTECTED BY FEDERAL LAW EXTEND-
ING TO TM ORMAL AS WELL AS ALL MODIFIED DERIVATIVE PLANS.
BUILDER ANDIOR OWNER MAY NOT PERMIT THESE DRAWINGS TO 13E
UTLM BY UNAUTHORIZED PERSONS FOR CONSTRUCTION OR
&ALM PURPOSES. NOR PERMIT THESE DRAWINGS TO BE REPRO-
DUCED OR COPIED, EITHER WHOLLY OR PARTIALLY UNLESS AUTHOR-
IZED IN WRITING BY NORTHERN DESIGN & BUILDING ASSOCIATES. LTD.
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