PT-0200-2022 Property Transfer Sewage Disposal Information Form
FV
C OWE
� LPR9 2022 ate:
Town of Queensbury 0d
742 Bay Road,Queensbury,NY 12804 TOWN O1=QUEENSDURY
P:518-761-8256 www.gueensbury.net BUILDING & OODES
i' (Name of Owner/Applicant)
Re: Onsite Wastewater Treatment System Inspection Information Request for:
7—LA`:3 91 OCR RnAZ
* (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 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 ��Q
John O'Brien, Director
BuJlding and Code Enforcement
Town of Queensbury
Property Transfer Packet Revised February 2022
Office Use Only
i Permit#:
Torn of CZucen uly Fee:
742 Bay Road,Queensbury,NY 12804
P:518-761-8206 or 518-761-8205 Invoice#: D ��
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)
Af Property address for inspection:
Tax map number: �1-►Dn '-� ��
Property owner:
Mailing Address (c/s/z): L<o go, rG vu G u
r i
Cell #: Land Line#: ,/F3C6
Email: 4� re Y`4UI;y eir .dam
Applicant (if different than above):
Mailing Address (c/s/z):
Cell#: Land Line#:
Email:
❑Proposed Owner ❑ Realtor ❑ Attorney ❑ Other (explain: )
Septic Contractor:_ / 6 S 5°,gyp T C
Mailing Address (c/s/z): 46 t(j f'k We..►"!/e)U qk c-�AINo LAVc�
Cell#: Land Line#:
Email: ww" 1 e4tc CCM
Reason for Inspection Request:
❑On the market ❑ Future listing Sale Pending ❑ Deed Transfer ❑Other:
Property Transfer Packet Revised February 2022
s
HOUSEHOLD INFORMATION
"PLEASE SEE SEPARATE PAGE FOR EXEMPTIONS"
P
# Bedrooms # Bathrooms # Kitchens_J_ Jacuzzi tub(s) Garbage grinder
Onsite Wastewater Treatment System:
How many systems are on the property?
Year system(s) installed: Tank A� Size of Septic Tank
Type of Absorption System: R .6?QV%v�-tz)
Are all system components wholly within the property boundaries? XYes ❑ No
Are system plans available? X Yes ❑ No
Does the system(s) serve multiple properties? ❑ Yes No
If yes, describe
Maintenance:
Service agreement? ❑ Yes I' 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 lNo
Direct surface discharge(s)? ❑ Yes ;�' No
Back-up of toilets? ❑ Yes "0
Back-up of any other fixtures? (e.g. slow drains) ❑ Yes �a'No
Seasonal ponding or breakout of leach field? ❑ Yes WN 0
Property Transfer Packet Revised February 2022
r
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 name: oL '*
z % a� ,
Signature: 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 leach field if there is no d-box.
Property Transfer Packet Revised February 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 11t timeframe, the
$2000 will be forfeited.
sirl 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.
DE E 0 W -
E
N 0 3 2022
TOWN OF QUEENSBURY
Property Transfer Packet BUILDING&CODE�evised bruary2022
❑ 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 11t 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: 4"�"Ce-WV Date .., d��
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Bum
Print Name: n'"g'''J.°""'"' _
w....,,�,sne.er Ny,.1!Mk .
*AWW in VMWnZ CiWW
Sign Name: rK,►C&MY"M tom 0 13,:hade: IL
Property Transfer Packet Revised February 2022
TOWN OF OVERNSBURY
BUILDING & ZONING DEPARTMENT a"��m
SETnTAGE EC r'DISPOSAL PERMIT APPLICA N P W
1. -Owner's Name / mi-Ri =T e � e I I APR 9 82
Address e TOWN OF OuF_r-ms€?i ir.,/
I : UILGI <<
Teleph--one No
2. Property location �- e •
. / �=r lPr �� T " (��rVo. �2A .
3. Name of person or firm responsible forinstalling system.
Telephone -No.
Address
4. Number of bedrooms .(residential buildings only)' '
5. Daily flow gallons/day
6. - Septic tank capacity (1 d ® gallons
7. Topography: flat rolling,• steep
�. of slope .
8. Nature of soilo'and' depth
9. If ground water; bey rock or impervious :material,is apparent at what
depth does it begin?.
10. Percolation test: -A is -required
B is not required- .
C If required .what is .the rate minutes/inch
ll:- Water- supply: municipal well, other
12. Type of system- proposed: drywell, tile. field,: other r=�Y�i/7�Ob�i r j .
Any contractor,. corporation, individual, etc-. -engaged: in: the.construction*
of a sanitary sewage disposal system who covers the .same before inspection,
does not have an approved•permit, or varies from the- approved application .
will be .subject to a penalty of $250 as provided -for in-Section 6.0-10 of the
Queensbury Sanitary Sewage Ordinance.
Date Ps a4, J
signature. of applican
On separate sheet of paper. submit a diagram ,of the. -proposed .septic system
..with all dimensions, including distance .from any:_structure, distance from_
property "line and do_ inestic water supply, etc. Include all dimensions of -:
the system itself-.
' `Form-3-82
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: 27 July 2023
To: Robert Gilchrist
(Applicant)
Re: System Inspection Site Report for:
2483 Ridge 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 from27 July 2023, the date of the inspection.
Sincerely,
A
John O'Brien, Director
Budding & Codes Enforcement
Town of Queensbury
/kd Revised March 2022
900 Route 146 Clifton Park, NY 12065
(P) 518.371.7621 edpllp.com
May 9, 2023
Mr. John O’Brien
Code Enforcement Officer
Town of Queensbury
742 Bay Road
Queensbury, NY 12804
Regarding: Congdon Residence Septic Certification Letter
2483 Ridge Road (Route 9L)
Queensbury, New York
Dear Mr. O’Brien:
In compliance with application approvals granted by the Town of Queensbury I offer the following regarding
the referenced project.
The design plans, prepared by this office, reviewed, and approved by the Town as associated with the
wastewater system application, are as follows:
Proposed Wastewater Replacement System For Gilchrist Residence 2483 Route 9L
Town of Queensbury
May 26, 2022
During construction Environmental Design Partnership LLP was on the job site to observe key components
of the system installation culminating with the ‘start-up’ of the pump assembly and control panel system on
May 5, 2023. I have provided an ‘as-built’ plan which indicates the system component locations. The pump
system was tested/inspected on May 5th with the pump and alarm working as designed. The time-dose
control panel was programmed for operation and the Owner was provided basic operational guidance.
Based on my inspection of the system installation it is my opinion that the wastewater system is in
compliance with the intent of the approved design plan and is ready for operation.
Sincerely,
Nicholas Zeglen, P.E.
Environmental Design Partnership
cc: Ted Congdon
Adirondack Septic Tank, Inc.
4720 State Highway 30
Amsterdam, NY 12010 US
518-842-1322
anne@adirondackseptic.com
adirondackseptic.com
BILL TO
Ted Congdon
2975 River Road
Niskayuna, NY 12309
INVOICE 52195
DATE 11/29/2022 TERMS Due on receipt
DUE DATE 11/29/2022
SHIP DATE
11/29/2022
DATE DESCRIPTION AMOUNT
11/28/2022 Norweco Singulair Green and Pump Station with WASP11P Control
Norweco AT1500 UV System 0.00
Myers ME3F-11 Effluent Pump 0.00
3 Year Service Plan (start up and 5 additional service calls at 6 month intervals)0.00
Delivery Charge 0.00
Capital Improvement 0.00
Thank You PAYMENT
TOTAL DUE $0.00
Adirondack Septic Tank, Inc.
4720 State Highway 30
Amsterdam, NY 12010 US
518-842-1322
anne@adirondackseptic.com
adirondackseptic.com
BILL TO
Ted Congdon
2975 River Road
Niskayuna, NY 12309
INVOICE 53129
DATE 05/15/2023 TERMS Due on receipt
DUE DATE 05/15/2023
P.O. NUMBER
2483 Ridge Rd, Queensbury
DATE DESCRIPTION AMOUNT
05/05/2023 Service on Norweco Singulair Green
Start up and programming
No Charge
0.00T
SUBTOTAL 0.00
TAX 0.00
TOTAL 0.00
TOTAL DUE $0.00
1" = 20'
WASTEWATER
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WASTEWATER AS BUILT SWING TIE TABLE
LOCATION 1 LOCATION 2 DISTANCE
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