PT-0468-2022 f
Property Transfer Sewage Disposal Information Form
Date: Z6 ZOZ Z,
Town of Queensbury
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.gueensbury.net g� (� @ W � = �
��� �� �/ J Dom.-" l� �1---
ii/if-c..1.4Af A/!y 7f,',n;5 GG' JUL 26 2022�
(Name of Owner/Applicant) M
Re: Onsite Wastewater Treatment System Inspection Information Request for: TOWN 1—BUILDING
C;t;SDJP.Y
IY p q co-,G CO
-rl 1*,Fg1 i2vXZ CGGf✓C:—R-12,VLG' AIZ /ZeZ0
(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 1st of the current, or following year (whichever comes first), a map locating the septic
system and payment totaling $2275 ($2000 refundable deposit plus $275 permit fee). The deposit is forfeited
if the owner fails to complete the repairs or installation as stated above.
If you have any questions, please call.
Phone: (518) 761-8256 Email: kated@queensbury.net
Thank you. '
Sincerely,
wl �o
�
JQhn O'Brien, Director
Biti�ding and Code Enforcement
Town of Queensbury
Property Transfer Packet Revised July 2022
Office Use Only
Permit#:�,,-T-06�a
Town of Qt cnsbun Fee:_$ Cil�r4 f
742 Bay Road,Queensbury,NY 12804 '7
P:518-761-8206 or 518-761-8205 Invoice#: 4.02-T,
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: 6—/ Aec.,VD CC.c3 VC-',eV 4q-' A19'
Tax map number: 2 26. /6 /�- /9
Property owner: Al c t-iAiy W C:TiVmz8�L
Mailing Address (c/s/z): ?D. z0ax 2S3 CLL-Vd—R`7t AGC A1Y/ZYZ o
Cell #:J71r-7S/'/ - 1917 Land Line#:
Email: /9/7 e, i2o.42)9cAVA x'Z• Co/n
Applicant (if different than above):
Mailing Address (c/s/z):
Cell #: Land Line#:
Email:
❑ Proposed Owner ❑ Realtor ❑ Attorney ❑ Other (explain: )
Septic Contractor: s67pTiG ,sL:fzOce
Mailing Address (c/s/z): PO ZaA /Y30 j<Pcz7p (�qAj% /y L„t ,)y iZ f'03
Cell #: Land Line#: Sf/S 793 - YY 'f 9
Email:
Reason for Inspection Request:
❑ On the market ❑ Future listing ❑Sale Pending Deed Transfer ❑ Other:
Property Transfer Packet Revised July 2022
HOUSEHOLD INFORMATION
"PLEASE SEE SEPARATE PAGE FOR EXEMPTIONS"
# Bedrooms 3 # Bathrooms 3 # Kitchens--� Jacuzzi tub(s) Garbage grinder
Onsite Wastewater Treatment System:
How many systems are on the property?
Year system(s) installed: Tank If76 Size of Septic Tank 0CI0
Type of Absorption System: yi-o'A/0Q)
Are all system components wholly within the property boundaries? 16es ❑ No
Are system plans available? ❑ Yes 2fNo
Does the system(s) serve multiple properties? ❑ Yes M/No
If yes, describe
Maintenance:
Service agreement? ❑ Yes dNo; If yes, business' name
Date of last inspection �zozz,N/A ❑ Date tank last pumped -3 2.:� toz2.N/A ❑
Frequency of pumping 3 r/dS N/A ❑
List known repairs/replacements, with dates:
Date Type of Repair/Replacement
Operation:
System problems? ❑ Yes [2 No
Sewage odors? ❑ Yes [2 No
Direct surface discharge(s)? ❑ Yes [ No
Back-up of toilets? El Yes [,�No
Back-up of any other fixtures? (e.g. slow drains) ❑ Yes RrNo
Seasonal ponding or breakout of leach field? ❑ Yes [� No
Property Transfer Packet Revised July 2022
i
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: W/LL114M Wc-iH�fLt3C�
11
Signature: �,r/liu. !✓.,�0Z___ Date: _?VZ7__
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
EXEMPTION CONDITION OPTIONS
Due to one of the conditions listed below, I am requesting an exemption from the
Septic Inspection Upon Property Transfer by the Town of Queensbury:
PLEASE CHOOSE ONLY ONE CONDITION BELOW IF YOU ARE REQUESTING A WAIVER
❑ 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, in which case the affidavit shall be accompanied by a site plan, including
adequate detail to demonstrate 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 within that 6 (six) 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. In order to qualify for the exemption, a notarized affidavit from the new property
owner to complete the requisite OWTS inspection within six months of the date of the conveyance of
real property, or June 1, whichever comes first,must be 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 a satisfactory OWTS
inspection from the Building and Codes Enforcement Office. If the Property Transfer
inspection is not completed within that 6 (six) month or June V timeframe, the
$2000 will be forfeited.
[� The property to be sold or transferred contains an existing OWTS 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 July 2022
❑ During the OWTS inspection, a failure of the septic system was determined. Due to winter and
frozen conditions,the repair to an existing OWTS could not occur or a new OWTS could not be
installed before the conveyance of real property. In order to qualify for the exemption, a notarized
affidavit from the new property owner to complete the installation or repair of the septic system within
six months from the date of the conveyance of real property, or June 1, whichever comes first,must be
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 installation 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 (six) month or June I't timeframe, the $2000 will be
forfeited.
❑ There is a record 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 complete all repairs/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 forfeiture 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 of a completed application.
Inspections scheduled to take place after the one year period will be 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 ARE OPTING FOR A WAIVER REQUEST!!***
I have read and understand the above notice regarding the expectations and possible forfeiture
of moneys submitted to the Town of Queensbury for an exemption request.
Seller:
Print Name:
Sign Name: Date:
Buyer: /
Print Name: W' C- M ►�/ c'%�i�G'T�3�'L�
Sign Name: Date: ' zG ZVZ Z'
Property Transfer Packet Revised July 2022
LOCATION SKETCH
IGR RAS
O•
, t @ = DISTRIBUTION BOX ACCESS
e 1 ® QE = SEPTIC TANK ACCESS
39 � ` QF = RECEIVER/PUMP ACCESS
i ' = 51'5" -
36'6"
24'0"
4'8"
21'5"
Hou- Sf
I
DESIGN BASIS
1. No. of bedrooms
2. Daily flow 450 gpd
3. Septic tank capacity 1000 gals.
4. Percolation rate 9 min/in.
5. Length of absorption field 260 ft.
NAME: - WETHERBEE
DATE: 2/28/09
The above sketch-shgws the locations of the units comprising your
sewage disposal system for future reference,in case of difficulty. It
shows measured distances from buildings,trees,garage, fence posts,
etc.,to septic tank,sewers,distribution box and absorption field or
seepage pits.
SAVE* * * * *POST IN BASEMENT* * * * * SAVE
To: John O'Brien, Director Building and Code Enforcement
From: Bill Wetherbee
Date: 7/26/2022
Subject: Property Transfer Sewage Inspection. 51 Mason Road, Cleverdale, NY
It was determined in March of 2022 that a new pump tank was required for the septic system
at 51 Mason Road to pass the Property Transfer Sewage Inspection. There were no functional
failures noted during the March inspection. However,the fact that the existing pump tank was
steel—even though it was still holding fluids—was a design failure. A new design to correct for
the steel tank was completed by Hutchins Engineering, submitted to The Town of Queensbury
and a permit was issued 7/6/2022.
The property has not been occupied since my father's passing, 8/6/2021. The house will not be
occupied until the septic system is improved. Unfortunately,there has been a significant delay
scheduling a contractor to complete the septic improvements.
A property transfer needs to be completed in August 2022. Due to the noted contractor delay,
it is most likely that a deed transfer will occur prior to completing a Property Transfer Sewage
Inspection.
Therefore, I am requesting a Waiver to allow the Property Transfer Sewage Inspection to occur
after the deed transfer.
Thank you.
Bill Wetherbee
MARIA A. GAGLIARDI
Notary Public, State of New York
Registration No.01 GA6061460
Qualified in Warren County
Commission Expires July 16,20
RESOLUTION GRANTING THE WILLIAM B. WETHERBEE TRUST
AN EXTENSION OF TIME TO COMPLETE WASTEWATER SYSTEM
ALTERATIONS ON PROPERTY LOCATED AT 51 MASON ROAD
RESOLUTION NO.: BOH 91,2022
INTRODUCED BY: Mr. Timothy McNulty
WHO MOVED ITS ADOPTION
SECONDED BY: Mr. George Ferone
WHEREAS, by Resolution No. 380, 2018, the Queensbury Town Board adopted Local
Law 2 of 2018 entitled "Septic Inspection Upon Property Transfer" which is set forth at
Queensbury Town Code Chapter 137 (Chapter 137), and
WHEREAS, by Resolution No.: 176, 2019, the Town Board adopted Local Law 5 of
2019 and by Resolution No. 47, 2020, adopted Local Law 1 of 2020 to make additional minor
modifications to Chapter 137, and
WHEREAS, Chapter 137 requires inspection of Onsite Wastewater Treatment Systems
(OWTS) prior to the transfer of ownership of certain real property and provides that a $2,000
escrow deposit will be forfeited to the Town in the event that completion of a wastewater
treatment system meeting all standards is not completed within the time provided as established
by Chapter 137, and
WHEREAS, by letter dated September 30, 2022, William Wetherbee on behalf of the
William B. Wetherbee Trust, (Applicant) advised that due to his septic contractor's schedule,
Applicant will be unable to arrange for completion of the upgrade of the existing septic system on
Applicant's property located at-51 Mason Road in the Town of Queensbury(Tax Map No.: 226.16-
1-19) by January 26, 2023 and therefore, Applicant has requested that the Town Board grant
additional time'(at least six months) to complete such'work and extend the date on -which the
$2,000 escrow deposit Applicant previously deposited with the Town shall be automatically
forfeited to the.Town, and.
WHEREAS, the Acting Director of Building and Codes Enforcement has recommended
Town Board approval of this requested extension to July 26, 2023,
NOW, THEREFORE, BE IT
RESOLVED, that the Queensbury Town Board, as the Town's Local Board of Health,
hereby authorizes and grants the William B. Wetherbee Trust additional time or until July 26,
2023 to obtain a certificate of compliance from the Town's Building and Codes Enforcement
Office as set forth in Chapter 137 for completion of the upgrade of the existing septic system
located on property located at 51 Mason Road, Queensbury and to extend the date on which the
$2,000 escrow deposit shall be automatically forfeited to the Town until such date of July 26, 2023
as delineated in this Resolution, with the condition that the property shall not be utilized for rental
until and unless the new replacement wastewater treatment system is installed, and
BE IT FURTHER,
RESOLVED,that the Town Board, as the Town's Local Board of Health,further authorizes
and directs the Town Supervisor and/or Acting Director of Building and Codes Enforcement to
and take any and all actions necessary to effectuate all terms of this Resolution.
Duly adopted this 7th day of November,2022, by the following vote:
AYES Mr. Strough, Mr. Metivier, Mr. Freer, Mr. Ferone, Mr. McNulty
NOES None
ABSENT : None
LANDS N/F OF
— M DREAM, LLC
,gip L'�JBACK
\ SHED
PUMP STATION REPLACEMENT PLAN
SCALE. I"--10'
GRAPHIC SCALE
5 0 2.5 5 10 20
( IN FEET )
CONTRACTOR TO FIELD VERIFY LOCATIONS AND DISTANCES
THIS IS NOT A FIELD SURVEY.
RECORD DRAWING DIMENSIONS
TABLE
CORNER "A"
CORNER "B"
PUMP STATION PORT
26'
13.5'
MAP REFERENCE:
1. BASE MAP INFORMATION FROM WARREN COUNTY GIS, AERIAL
PHOTOGRAPHY, AND FIELD MEASUREMENTS. THIS IS NOT A FIELD
SURVEY. ALL LOCATIONS ARE APPROXIMATE. CONTRACTOR TO
FIELD VERIFY ALL SETBACKS PRIOR TO BEGINNING INSTAH AWON.
2. NORTHERN NEIGHBORING PROPERTY INFORMATION FROM "MAP OF
LANDS OF ANGELA M. AND ROBERT P. KLADIS, SHOWING THE
LOCATION OF THE RESIDENCE, LOCATED ON AUGUST 7, 1997," IN
THE TOWN OF QUEENSBURY, WARREN COUNTY, NEW YORK. DATED
AUGUST 7, 1997 PREPARED BY COULTER & MCCORMACK
LICENSED LAND SURVEYORS.
J. SOUTHERN NEIGHBORING PROPERTY INFORMATION FROM "MAP OF
LANDS BELONGING TO ROBERT L. EVANS, IN THE TOWN OF
QUEENSBURY, WARREN COUNTY, NEW YORK. DATED JUNE 19,
1989. LAST REVISED AUGUST 11, 1993. PREPARED BY COULTER &
MCCORMACK LICENSED LAND SURVEYORS.
WASTEWATER SYSTEM SETBACK REQUIREMENTS
PROPERTY LINE
HOUSE
STREAM, LAKE,
WATERCOURSE,
WETLAND
WELL
SEPTIC TANK
10'
10'
50'
50'
ABSORPTION FIELD
10'
20'
100'
100'
SITE LOCATION --I LOCATION MAP
EXTERIOR WEATHERPROOF JUNCTION BOX (IF NECESSARY).
SEAL CONDUIT GAS TIGHT. INSTALL CONTROL PANEL IN HOUSE.
ALL ELECTRICAL WORK TO BE INSPECTED BY A CERTIFIED
ELECTRICAL INSPECTION AGENCY PRIOR TO START-UP OF PUMP
STATION.
TRANSITION TO 4" 12" MIN. COVER
OUTSIDE OF D-BOX DISTRIBUTION BOX
CONCRETE BAFFLE
1-112" USE SPEED LEVELERS TO
L�FORCEMAIN ASSURE ALL OUTLETS ARE AT
EXACTLY THE SAME ELEVATION
BALL VALVE 4" PVC SDR-35 SOLID HEADER TO
ABSORPTION LATERALS, 118" PER
FOOT MIN SLOPE
F
16" MIN.
1. d
4'0 PRECAST CONCRETE
MANHOLE USED AS
PUMP STA71ON
INSTALL FLOAT SWITCHES TO
OPERATE PUMP AND MAINTAIN
LEVELS AS INDICATED
PUMP STATION DETAIL
SCALE. NTS
1-1/2" SCH-40 PVC PIPING INSIDE WET
WELL THROUGH WALL
UNION - LOCATE SUCH THAT UNION
CAN BE DISCONNECTED AND PUMP
REMOVED WITHOUT TANK ENTRY
REDUCING TEE POINTED DOWNWARD WITH 1"
BALL VALVE THROTTLED TO ALLOW TRICKLE
DRAIN BACK INTO WETWELL
BALL CHECK VALVE
GOULDS WE03L PUMP
W
TO FIELDSTATIONUIRED
A REPRESENTATIVE OF OUR OFFICE VISITED THE SITE
DURING CONSTRUCTION AND IT IS MY OPINION THAT
THE SYSTEM IS INSTALLED IN GENERAL CONFORMANCE
WITH THE APPROVED PLAN AND THIS RECORD
DRAWING. FINAL SURFACE FINISHING AND TURF
ESTABLISHMENT IS ONGOING
G. THOMAS HUTCHINS, P.E.
71512023
EM Call Before You Dig
Wait The Required Time
IM Confirm Utility Response
EM Respect The Marks
IM Dig With Care
800-962-7962
www.digsafelynewyork.com
2" MIN.
2" MIN. DROP
BETWEEN INVERTS
PUMP STATION NOTES
SEAL ALL TANK OPENINGS WATERTIGHT.
PROVIDE AND INSTALL UL LISTED PACKAGED PUMP
CONTROL PANEL WITH VISUAL AND AUDIBLE ALARM.
INSTALL SIMPLEX, DEMAND DOSE CONTROL PANEL
INSIDE HOUSE IN ACCESSIBLE LOCATION.
INSTALL POWER & CONTROL WIRING TO CONTROLLER
IMTH ALARM IN HOUSE IN ACCORDANCE WITH
MANUFACTURER'S INSTRUCTIONS AND NA71ONAL
ELECTRIC CODE (N.E.C.) REQUIREMENTS.
PUMP CONTROL AND FLOAT LEVELS TO BE INSTALLED
TO PROVIDE A 40-50 GALLON DOSE.
EFFLUENT PUMP TO BE GOULDS PUMPS WE SERIES,
MODEL WE03L SUBMERSIBLE EFFLUENT PUMP 113 HP,
230 VOLT, 1PH
VERIFY EXISTING ELECTRICAL SERVICE PRIOR TO
PURCHASING PUMP.
ALL ELECTRICAL WORK TO BE INSPECTED BY A
CERTIFIED ELECTRICAL INSPECTION AGENCY PRIOR TO
START-UP OF PUMP STATION.
INSTALLATION DATE: 612912023
INSTALLED BY - CRANDALL EXCAVATING, INC
TAX MAP # 226.16-1-19
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: 6 July 2023
To: William Wetherbee
(Applicant)
Re: System Inspection Site Report for:
51 Mason 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 July 2023, the date of the inspection.
Sincerely,
A
John O'Brien, Director
Budding & Codes Enforcement
Town of Queensbury
/kd Revised March 2022