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PT-0208-2023 Property Transfer Sewage Disposal Information Form ---��' Date: 1/1!J_y 0 2! Town of Queensbury 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.gueensbury.net lk�ece !f',.esS i (Name of Owner/Applicant) Re: Onsite Wastewater Treatment System Inspection Information Request for: Aj (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 bestjob 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 15Y 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, J-- V'j E 3 d TG��l. P,jr! N ' t tom„ John O'Brien, Director '_...W. BOJding and Code Enforcement Town of Queensbury Property Transfer Packet Revised July 2022 l f.� Office Use Only Permit#: ©20� - ZO2� Town of( 5 ury Fee: 742 Bay Road,Queensbury,NY 12804 P:518-761-8206 or 518-761-8205 Invoice#: �Q 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: efr G, ,�5; Tax map number: Property owner: 5T., fyC/.�`t'�VE.0 Mailing Address (c/s/z): �90 Al2:>x 'qZo CL�V� .41Y /2k-92,z-� r Cell#: Land Line#: Email: 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): 44�2 44,Q77— 4217 Cell#: /--D 21!q Land Line#: Email: t"i^ Reason for Inspection Request: ❑On the market ❑ Future listing ❑Sale Pending [Deed Transfer ❑ Other: Property Transfer Packet Revised July 2022 s HOUSEHOLD INFORMATION "PLEASE SEE SEPARATE PAGE FOR EXEMPTIONS" # Bedrooms . # Bathrooms # Kitchens Jacuzzi tub(s). / Garbage grinder Onsite Wastewater Treatment System: How many systems are on the property? Year system(s) installed: Tank 2,b1cam Size of Septic Tank-521PType of Absorption System: Z_Z___<5�E_Aj Are all system components wholly within the property boundaries? ❑Yes ❑ No Are system plans available? [�es ❑ No Does the system(s) serve multiple properties? ❑ Yes [g' l�o If yes, describe ): Maintenance: Service agreement? P'Y' es ❑ No; If yes, business' name Date of last inspection 2-Z- N/A ❑ Date tank last pumped /� Z_Z_ N/A ❑ Frequency of pumping LX 1,3VIL N/A ❑- List known repairs/replacements, with dates: Date Type of Repair/Replacement AIA Operation: System problems? ❑ Yes P'No Sewage odors? ❑ Yes 0-'No Direct surface discharge(s)? p Yes @'No Back-up of toilets? ❑ Yes D"No Back-up of any other fixtures? (e.g. slow drains) ❑ Yes Ems] No Seasonal ponding or breakout of leach field?- ❑ Yes 2IN0 Property Transfer Packet Revised July 2022 Statement of Acceptance of Conditions: 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-spac',es 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: U?6wner ❑agent ❑other: Please print n e: Signature: .� Date: D K, -3 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 iREA1�IIENT� `UNIT_/ ;EFFLUENT Pint I AW= PUMP-STATtOW rwb34. , e' 140 M 24M� y... ~'� � ' �� � 1 SANITARY MANHW ti `V comft sup . *mob -- •r,,�; ft OPROrANC r � i DIS1R1®U110N� ! j 1 1Bgx , AREA 00870 0.20 sores ` ! 1 40 •Lf° OF ELEN •., ... . _ 44 E 3 ` i IN—DRAIN UNITS 4'PLASTIC MPC 1 ` INv-327,09 f 1 mm.wa71 p 1 r r•n�� `�• i ) AWN ore-, UUM CIA at ai 227.13-2-36 PT-0208-2023 .i'-;��+.i<z. ii�r..'::��>i'�';•"in=`.''=::r~�i:;�iii'�w.. ;Efyiy'7, f Seaboyer, Steven =e:M,;:c�"r�;�:t�;�.''.S" &z•++;Si iip''+'�+`5..:�;r;�.t..�' q,h:4f'{:,i. ��"� . :; ,` F ,. •.,>G :.:, . ;, 83 Rockhurst Property -p rty Transfer deed transfer 8MMANDSERVICE UMTS-FLO&EMY SERVICE COfnTMCF' mftco"Iradvabobeti fora peftdofbmbe awnft*or&"the -A on Greoprelimis I VPMMoewof Dmqgftsm-dwpadmd=scffed senice COS wd dom the ffiffsocks mm bcakdat Ad&= 83RocWwmtRd Mr- Cbmide SUftNcwYc* rjpl2S2O comw- A. 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JaMWE.VmnchSr. Resided P& CMtbd Hes"a COGRAM kv- ofteuse 447MOdRd GaravtmL NwYixk UM Pft Ciel@"36143M 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 June 2023 To: Steven Seaboyer (Applicant) Re: System Inspection Site Report for: 83 Rockhurst 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 from9 June 2023, the date of the inspection. Sincerely, A John O'Brien, Director Budding & Codes Enforcement Town of Queensbury /kd Revised March 2022