PT-0232-2023 Property Transfer Sewage Disposal Information Form
Town of Queen ry Date:
5 (Z,:5
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.gueensbury.net
Wb("A �� �2u 1, eUC6 A-�&Z-_- 7U!91
(Name of Owner/Applicant)
Re: Onsite Wastewater Treatment System Inspection Information Request for:
(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. Priorto 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 r this service is$275. Be advised that all fees must be paid prior to
.scheduling the inspection. We require 8 h notification prior to scheduling the inspection.
If the purchaser is requesting an exempti n, 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 follow' a map locating the septic
system and payment total! $2275 ($2000 refundable deposit plus$275 permit fee). he deposit is forfeited
if the owner fails to completed a repairs or instal ation as stated above.
If you have any questions, please call.
Phone: (518) 761-8256 Email: kated@queensbury.net
Thank you.
D � y7
Sincerely,
MAY 0 9 2021
O�VP4 OP
�� U�
BUILDING,?, r�0�`g y�
John O'Brien, Director
BUilding and Code Enforcement
Town of Queensbury
Property Transfer Packet Revised February 2022
1
- Office Use Only
Permit#: Fr- 0 22z>2- 20Z3
Town or(Ln'rnsbun' Fee:
742 Bay Road,Queensbury,NY 12804
P:518-761-8206 or 518-761-8205 Invoice M
www.gueensburv.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: l� ►'J
23�]DD
Tax map number:
Property owner: -Dm1t> �j
Mailing Address (c/s/z): LkS r 5 +�� 1 1��U 1�1 J� '� U I
Cell #: 510 — ?)N— Land Line#:
f _
Email: w(N 5offijail -
Applicant (if different than above):
Mailing Address (c/s/z):
Cell #: / Land Line#:
Email:
❑ Proposed Owner ❑ Realtor ❑ Attorney ❑ Other(explain: )
Septic Contractor: DY)
Mailing Address (c/s/z): 54h 6�U6 k Iy
Cell#: Land Line#:
Email:
'MAY 202
Reason for Inspection Request: FOVVN OF Q1LJEEtiJSE.URY
BUILDHG 8,OOUFEE
❑On the market ❑ Future listing ❑Sale Pending eed Transfer ❑Other:
Property Transfer Packet Revised February 2022
HOUSEHOLD INFORMATION
"PLEASE SEE SEPARATE PAGE FOR EXEMPTIONS"
# Bedrooms # Bathrooms .5 # Kitchens Jacuzzi tub(s) Garbage grinder l
Onsite Wastewater Treatment System:
How many systems are on the property?
Year system(s) installed: Tank Z004 Size of Septic Tank i floo�o.�
Type of Absorption System: U ab� �-41
Are all system components wholly within the property boundaries? Yes ❑ No <
yl
- Are system.plans-available? eYes ❑ Noi ,�Jt Wn bw+
Does the system(s) serve multiple properties? ❑ Yes 21/No
If yes, describe
Maintenance:
Service agreement? ❑ Yes No; If yes, business' name
Date of last inspection N/A [r Date tank last pumped N/A ❑
Frequency of pumping 4-5`$t�, N/A ❑
List known repairs/replacements, with dates:
Date Type of Repair/Replacement
C9_-1
Operation: �
System problems? ❑ Yes Ej No
Sewage odors? ❑ Yes p No
Direct surface discharge(s)? ❑ Yes Fj"N'o
Back-up of toilets? ❑ Yes �
Back-up of any other fixtures? (e.g. slow drains) ❑ Yes No
Seasonal ponding or breakout of leach field? ❑ Yes F3�No
Property Transfer Packet Revised February 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 20% of the fee is retained by the Town of
Queensbury.
Signature of property owner or authorized agent:
Affiliation: owner ❑agent ❑other:
Please print n e:
Signature:
Prior to scheduling with the Town of Queensburv, 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 February 2022
Application for Permit-Septic bisposal System - -
Town of Queensbury 742BayRoad Queensbt6y,NY.12804 (518)761-8256
1. OWNER INFORMATION;
2q viaW-i�G.E�-IPA-.�'r-11— office Use
Location of installation: 1f1Wa 6F Qi/;&*&Rl�LI•''
File PermitNo.2L�a
Tax Map No.
Fee Paid
Owner's Nam 2e: 1•4 . 1-fos 0AVO
7 g2tn✓iJ
Address: i �� A GM061 1.11t" 12 Co(n
2. INSTALLEWS NAME : PHONE NO.
3. RESIDENCE INFORMATION: (circle year•of dwelling,indicate#bedroom(s)and multiplRof C E I VE D
bedrooms with applicable gallons per bedroom to equal total daily flo�jw
Year of House: No of Bedrooms x Computation = Total Daily Flow DEC 3.0 20OZ
SBURY
1980 or older x . 150 gal/bdrin = TOWN OF C AND CODE
.
1980—1991 x 130 gallbdrai =
1991—present _ x 110 gal/bdrm
Garbage Grinder Installed yes_ / no .
Spa or Whirlpool Installed yes_ / no
4:• PARCEL INFORMATION: (circle applicable information&indicate'measurements)
Topogmphy Soil Nature Ground Water Bedrock or envious Material Domestic Water Su 1
Flat an at what depth at what depth municipal
oiling to ____feet. _feet well
Steep slope el . if well;water supply
_%slope other from any septic-system
depth:' absorption is ICQ-t-
other
Percolation Test- (To be completed by licensed professional engineer t)or architec
Rate: 7 minute per inch
5. PROPOSED SYSTEM: For New Construction: All individual sewage disposal systems must be designed by a licensed
professional engineer or architect(unless installed n a Planning Board approved subdivision). Add 250 gallons to the size
of the septic tank and leach field for each Garbage Gainder,Spa or whirlpool Tub.
Septic Tank: 1160 gallon(min.size 1,000 gal.)
Tile Field: each trench f Total System Length: ti
Seepage Pit(s): number of____,______ slze ofeach: by ft.
Size of Stone to be used: # /depth or thickness feet
Bed System Size: x .
� UtJ FT or- I:l,-1c,J
Alternative System: length andlor size 10 m:md -SelPTI G F1&
6. HOLDING TANK.SYSTEM: (if required)
Number of tanks: / Size of each: gallons /TOTAL Capacity: gallons
- ' Note:Alarm"Systam and associated electrical work must l;inspected by a Town approved
electrical inspection ageiidy.
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Septic Inspection Report
Office No.(518)761-8256 Date Inspection request received: -
Queensbury Building&Code Enforcement Arrive: am/ epart: am/p
742 Bay Rd.,Queensbury,NY 12804 Inspector's Initials: 0
NAME: PERMIT NO.:
LOCATION: f cx CrJ INSPECT ON: Ili U
RECHECK:
Comments and/or diagram
Soil T : Sand/L ClayI _
Type of Water: Municipal/Well Water —�oAGC z1p Z fiPpfit� kA IC C— T° D`(�
Waterline separation distance
Well separation distance
Other wells: ft.
Absorption Field: Total len ,L E ft.
Length of each trench v ft !� ,� 1 c.
Depth of trenches ft.
Size of Stone
Seepage Pits: Number
Size: x
Stone Size:
Piping Si ( Type
Building to tank t b
Tank to Distribution Box
Distribution Bo Field/Pit
Opening Sealed: N/Partial
Location/Separations
Foundation to tank ft.
Foundation to absorption Zft.
-Separation of Pits ft
Conforms as per Plot Plan Y N �V ; A.5 /J V r L
Location of System on Property:
Front Rear Left Side Right Side A5�
. Middle Front fiddle Rear .
System Use Status
Approved C)K t b C O UC�
Partial Approved and needs to be re-inspected,please call the Building&Codes Office
Disapproved
L:�SueHemingwayV3uilding.Codes.Inspection.FORMS\,Sepdc Inspection Reportdoc January28,2003
y
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: 7 June 2023
To: David M Brown Revocable Trust
(Applicant)
Re: System Inspection Site Report for:
29 Knox 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 from?June 2023, the date of the inspection.
Sincerely,
A
John O'Brien, Director
Budding & Codes Enforcement
Town of Queensbury
/kd Revised March 2022