PT-0283-2023 Office Use Only
Permit#: "'
Town ref CZucevsl,un Fee:_$ G- 1 ✓
742 Bay Road,Queensbury,NY 12804 I
P:518-761-8206 or 518-761-8205 Invoice#: Uc ��
www.aueensbury.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: 10 8 k1 A a rGt do ,-%- ec:+ Q aens6ru_ N
Tax map number: 30 q. 19- 1 - 4
Property owner: qf,+erT. 4 susah f�. &Gkno
Mailing Address (c/s/z):1gg &jel1g An-,QYI
Cell #: 3 18- 8(Z- 11 I Land Line#: 51S-7q'2- 1707
Email: I . tDni
Applicant (if different than above): �y o ® �
oVV4 �
Mailing Address (c/s/z): ��joi 0� � )l�
SQ
Cell #: Land Line#: �` `'r- .L� `s
Email:
❑ Proposed Owner ❑ Realtor ❑ Attorney ❑ Other (explain: )
Septic Contractor: c7kt ayl
Mailing Address (c/s/z): ig o 0 � . (26s-FcL C
Cell M Land Line#: J (S"7? 3 -
Email:
Reason for Inspection Request:
❑On the market ❑ Future listing ❑Sale Pending ®'Deed Transfer ❑Other:
Property Transfer Packet Revised July 2022
Property Transfer Sewage Disposal Information Form
arma
Town of Queensbury Date: -57 3 0 23
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.gueensbury.net
(Name of Owner/Applicant)
Re: Onsite Wastewater Treatment System Inspection Information Request for:
klekaalsrnn e s
(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 V 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,
John O'Brien, Director
BuJding and Code Enforcement
Town of Queensbury
Property Transfer Packet Revised July 2022
HOUSEHOLD INFORMATION
"PLEASE SEE SEPARATE PAGE FOR EXEMPTIONS"
# Bedrooms # Bathrooms # Kitchens Jacuzzi tub(s) ZGarbage grinder_,Z
Onsite Wastewater Treatment System:
How many systems are on the property?
Year system(s) installed: Tank� Size of Septic Tank J.60 ga`Irrt.
Type of Absorption System: . J
Are all system components wholly within the property boundaries? N Yes ❑ No
Are system plans available? ❑ Yes ❑ No
Does the system(s) serve multiple properties? ❑ Yes ® No
If yes, describe
Maintenance:
Service agreement? ❑ Yes No; If yes, business' name
Date of last inspection N/A j2r Date tank last pumped 2/ 22 N/A ❑
3
Frequency of pumping - N/A ❑
List known repairs/replacements, with dates:
Date Type of Repair/Replacement
Operation:
System problems? ❑ Yes No
Sewage odors? ❑ Yes lg 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? ❑ Yes '� No
Property Transfer Packet Revised July 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 30% of the fee is retained by the Town of
Queensbury.
Signature of property owner or authorized agent:
Affiliation: 'owner p agent ❑other:
Please print name: SIALay\ --�g i 56Ap
Signature: Date: 430
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
V moo
40
77
TOWN OF EENSBURY
B AIL ING ODES 'DEPT.
7-3242,�u� REVIEWED BY
DATE
gt S
ru
0,venos d 7 7'
5��
s m�*.;`t`'rY"TSz'e�`>�s''�� '�i y.r�m.<t'° ,:gti g .}::..y��, 3t:Y.r,,•.,";:..r>..
u ��� (—
° TOWN OF QUEENSBURY TO€ OF'�QUEENSBURY
BUILDING CODE EP�FORCEMENT BUILDING & CODE ENFORCEMENT
531 Bay Road �,:. 531.Bay Road
Queensbury NY 12804 Queensbury NY 12804
518-745-4447 518-,74,5-4447
SEPTIC DISPOSAL SYSTEM INSPECTION SEPTIC- DISPOSAL SYSTEM INSPECTION
s:.
Name !.��16k� Name PC* �jo0
Location j Location (0
�� �,�' ��(�',�`3�1
Date (, Permit f �.# -En ��� ? Date . ,�j_ q� Permit # "
j
SOIL TYPE: Sand-Loam-Clay- SOIL TYPE: Sand-Loam-Clay
jv:
Results of Percolation Test Results of _Percolation Test-
.(if applicable) Rate-Minute/Inch }.. (if applicable) Rate-Minute/Inch
TYPE OF SYSTEM: TYPE OF SYSTEM:
ABSORPTION FIELD: Total Length ABSORPTION'FI'ELD: Total Length 2Q
Length of each trench Length of .each.trench
'c7
Depth of trenches `, Depth of trenches 2
Size of stone Size of stone Z,
SEEPAGE PITS: Number SEEPAGE PITS: Number-
Size - ft. x ft. Size - ft.
Stone size. Stone size .
PIPING:. Size Type PIPING: Size Type
Bldg. to Tank ' Bldg. to` Tank 4/ S'_1 a C/c
t,
Tank to Dist. Box Tank_.to Dist. Box -
Dist. Box to Field/Pit ', Dist. Box- to Field/Pi t
Openings Sealed? Yes No Partial ;'; Openings Sealed? Yes No Partial
LOCATION/SEPARATIONS: LOCATIM/SEPARRTI ONS:
Foundation to Tank feet Foundation to Tank. feet
Foundation to Absorption feet :5 Foundation to Absorption '....._.: feet
Separation of Pits feet Separation of Pits feet
Conforms as per Plot Plan Yes No Conforms as per Piot .PIan Yes No
LOCATION .OF SYSTEM ON PROPERTY: . LOCATION OF SYSTEM ON PROPERTY::;
(circle one 1.. (circle one)
Front eater - ,Left Side - Right Side T;: Front Rear - .Left Side - Right Side
Middle wont - Middle Rear Middle Front - Middle Rear -
COMMENTS: COMMENTS:
- � 0(�
!
A vL- car p1p6—s Fat. L/r5-r-z
SYSTEM.USE APPROVE®: YE NO I �SYSTEM.USE APPROVED: YES NO
i <
Arrived: Arrived:
Departed: Departed:
Building Inspec o y Building 7pect.or
4�'s
SIGNORELLI & SON, INC.
Plumbing & Heating �)
RD 2 Box 237 West Mountain Rd. .
QUEENSBURY, NEW YORK 12804 6395
(518) 792-1600
_....
.......
..................
f-11----------------'- _......................._..__........ ....._............ _ DATE.,_ _._ ....._...._..__. JOB NO._...
-- ------------ __ ...._.._—._ ._.__..._._........_....... _._._..... __ ._.__....._...._. _ JOB NAME
_...__...._...................... .-- --
f ..(..,. 1...............
.....
..........................
_.... .......
....
_....__...._.... JOB LOCATION. ...__..... �I� J� _ _.__. ............._... —_
-------------
TERMS
DESCRIPTION PRICE AMOUNT
__......._._._........
__._........._...................._..........._......_.._...__r� �G�(%�.._. .._..._...___.................... ......._... _.. ..__ .. __......._._........ __..._........._.._._.._ _ _.........__........
...... .
............
................................ ................... ............ ........................................ ...........................................................................................
...........................
..............
---------------------
-----------
_ _.___...................__ _._..._ ... _. _. r._..._....:..._..�£aa. /f -
_ G _._...._..._!
............. ........
.......................................................................................... ...... .......................................... ................................ ......... ..........
........................... ........... ........................................................
..............
...........
.............
...............................:__ _.........._._. ._....._........._.1.._.........................__..__........................................... ......... .__................ito .... ........................_.................
20
............ _....._...
1
�—
__ _..___...__._.___ .._.....__...._..__ ____.___.._._.._.._
ORIGINAL 40%Pre-Consumer Content
PRODUCT209®®Inc.,To Order PHONE TOLL FREE 14*n5-= 10%Post-Consumer Content �lTw
'-. .. __ _. _ •_. , .,��_____ Page No: . .of Pages
Vig j , - -
SiGNORE
Piuinbing &."Heating
RD 2.: Baker.Road
QUEENSSUR�,.-i>tEiN,'Y®RdC_128 4'
` PROPOSAL'.SUBMITTED T0, f' �� r; . : PHONE : DATE:
if It !' d r
{ STREET F' .y ! v JOB NAME =_
CITY, STATE.AND ZIP CODE „n^ •/ JOB'LOCATION
ARCHITECT. - •" - - - - ,K -DATE OF'PLANS - • "-/ y" — - - .JOB,PHONE .•i
We_her6:by_subiriit specifications and estimates for:
¢.ram j'1� /, i-. ��..- '_ :.-� � - - ,•
zw� Cr� ! to r�Yeti�r3t r 2 [r' I
I ; �,�� _ ,• ��-�` `�,-: :.etc .i��,� ���-,��.,�.; ����� � �� � S'G'
47
i r VrvpaogP hereby to-furnish material"and labor -complete in.-accordance with;above specifications, for fhe:,sum of: -
`s
} /GG d ft'GC%'r� Gc C ,t fuif dollars.($
Payment to be made as follows:
All material is guaranteed to.be as specified.All.work to be completed in a workmanlike
I 'manner according'to standard practices.Any alteration or deviation from'above specifica- AUtfiOrized -
tions.involving extra costs-will be executed only upon-written"orders,and will become an Signature _
extra charge"over and above the'estimate:All agreements contingent upon'strikes,accidents.• -r {
or-delays beyond our-control.Owner to carry fire,tornado and otheflnecessa Note:This ro o, y
y y ry insurance. p p sal may be -
•`
Our workers are-fully covered by Workmen's Compensation Insurance." ' - withdrawn by us if not accepted within days.' '
�. ,3�raptafirr of x � M�-Tfie above prices, specifications ' (e ' F1
a and conditions_,are satisfactory•and are hereby•accepted. You are.authorized ' Signature
( to do the work as.specified..Payment will be ade a outlined above.-..
I _ L
Date of Acceptance: L Signature .
PRo0UCT 118.3, Inc,won.Mam 91471.To Order PHONE TOLL FREE 1-40225.6380
\ ,-PIP&RSID
114" PER FOOT
MN, SLOPE
4" HOUSE SEWER
PVC SOR-35 OR SLF1-O
WATERTIGHT SLEEVE-1
SEAL (nP)
t
t
EX57M 1,000
GALLON
CONC>iE7E SEPTIC
t
t
t
TANK
1000 GALLON
\ \ SEPTIC TANK
� t
t
� t
\ t
\ W
� 1
WASTEWATER SYSTEM PLAN
SCALE: 1 "=30'f
GRAPHIC SCALE
15 0 7.515 30 60
IN FEET
CONTRACTOR TO FIELD VERIFY LOCATIONS AND DISTANCES
THIS IS NOT A FIELD SURVEY.
RECORD DRAWING
INSTALLATION DATE: 8110123
INSTALLED BY - SANITARY SEWER SERVICES
RECORD DRAWING NOTE:
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
REMAINS TO BE COMPLETED.
THOMAS CENTER JR., P.E.
8113123 A
TO GRADE WIN TAAM
RESISTANT ACCESS COVER
E TANK 6 GREATER THAN
12" BELOW GRADE
(NON-T RMFTC AREAS)
'TEE BAFFLE
12" W!L COVER
e, : • ' i :• ' w 1/g" PER FOOT 12" ON. COVER
MI!L SLOPE AIS7!l7ION BOX
Lmm LEVEL 4" EFFLUENT SENER
•.' PVC MR-35 OR SO4-40 BAFFLE
M7N USE SPEED LEVELERS TO
. ASSLW ALL OUTLETS ARE AT
EXACTLY THE SAME' ELEVATION 2, AM DROP
' 4" PVC SOR-35 SOLED HEADER BETNEEM INVERT
TO AMW710N FIELD, 1/$"
PER FOOT MIN SLOPE
SEPTIC TANK NOTES
s ALL UNITS SHALL COMPLY W►774 THE REQUIREMENTS OF THE NEW YORK STATE
DEPARTMENT OF HEALTH AND SHALL BE OF PRECAST CONCRETE AS
MANUFACTURED BY UTOPIA ENTERPRISES OR EQUIVALENT.
,. ALL STRUCTURES SHALL BE PLACED ON FIRM, COMPACT SAND OR GRAVEL BASE
WHERE EXISTiNO SOIL CONDITIONS ARE UNSUITABLE CRUSHED STONE SHALL BE
PLACED AS NECESSARY 70 ACHIEVE A STABLE BASE
::•' :: , ' : ,•• .: y e '� ' SEPTIC TANKS INSTALLED IN TRAFFIC AREAS SHALL BE OF EXTRA HEAVY
NEW 1,000 GAL.. PRECAST CONCRETE SEP77C TANK CONSTRUCTION DESIGNED FOR H-20 WHEEL LOADING
ALL JOINTS MUST BE SEALED WITH BUM SEALANT. JOINTS BELOW THE LIQUID
LEVEL MUST BE TESTED BEFORE BACKh7WNG
SEPTIC TANK DETAIL
NTS
4" PVC PERFORATED LATERAL
INSTALLED LEVEL, IN BED
CONFIGURATION WITH MAN/FOLDEO
WASTEWATER SYSTEM DESIGN
3—BEDROOM DESIGN
WATER SAVING FIXTURES
(1.6 GPF MAX. FLUSH, 3.0 GPM MAX. FAUCETS)
DESIGN FLOW — 110 GPD/BEDROOM
SYSTEM DESIGN FLOW — 330 GPD
SEPTIC TANK
EXISTING 1000 GAL PRECAST CONCRETE TANK
LEACH FIELD —STANDARD PIPE —IN —STONE ABSORPTION BED
DESIGN PERCOLA7ON RATE = 1-3 MIN/IN
APPLICATION RATE = 0.90 GPD/SF
ABSORPTION BED AREA REQUIRED = 367 SF
500 SF TOTAL TO BE PROVIDED
20 FT WIDE BY 25 FT LONG ABSORPTION BED
PROPOSED
POTABLE WATER FROM MUNICIPAL WATER SYSTEM
4" TOPSOIL COVER 5 FT CENTER TO CENTER {TYP.) ENDS FILTER FABRIC
ABOVE TOP OF STONE MIRAFI 14ON OR EQUAL
BED; 2.5' TO EDG
6-
SEED & ESTABLISH OF BED 2' TYP•
TUR
8—I
>.. c
I tr., '•A � t ti. . i•
}
COVER is ,): :t.. ••i. >P> ia'. ' t,` :'{-• '.y.'♦
� v
" 12 TOoE DPIPE MIN S20 FT �WfDE BED LOW PIPE
BE
SEPARATION
i♦
S \ ♦ C .♦
PTO BOUNDARY..:
S
3/4"-1-1/2" WASHED
CRUSHED STONE
LIMIT OF 20'x25'
STONE BED
20'
ABSORPTION BED PROFILE
NTS
ABSORPTION BED PLAN
NTS
AMENDED SOILS WITH A PERC RATE
OF 1-3 MIN/IN. SEE AMENDED SOILS NOTES
. " t1 r-,1 r-A r1 • Tr•I1 - 1 -
Dig Safely.
New.York
■ Cali Before You Dig
■ Wait The Required Time
■ Confirm Utility Response
■ Respect The Marks
■ Dig With Care
800-962.7962
www.digsafolynowy—k coin
MAP REFERENCE:
BASE MAP INFORMATION FROM WARREN COUNTY GIS
MAPPING AND FIELD MEASUREMENTS BY CENTER
PROJECT SERVICES
SITE SOILS DATA
TEST PIT
TR1 717123 BY TOM CENTER, P.E.
0-7" — TOPSOIL
7-18" — LOAMY MEDIUM FINE SAND
18-74" — MEDIUM FINE SAND
NO MOTTLING OR GROUNDWATER OBSERVED
ROOTS TO 58"
PERCOLATION TEST
PT-1 — 717123 BY TOM CENTER, P.E.
—TEST AT 24 INCHES BELOW GRADE IN A 30 INCH DEEP HOLE
STABILIZED PERCOLATION RATE: 3 MINUTES 10 SECONDS
W/W SYSTEM INSTALLATION NOTES
• CONSTRUCTION SHALL BE AS SHOWN ON THIS DRAWING AND IN
ACCORDANCE WITH THE N.Y.S. DEPARTMENT OF HEALTH INDIVIDUAL
HOUSEHOLD SYSTEMS AND ASTM F481 INSTALLATION OF
THERMOPLASTIC PIPE AND CORRUGATED TUBING IN SEPTIC TANK
LEACH FIELDS
• AFTER EXCAVATION OF BED TO THE DEPTH REQUIRED, THE WALLS
AND FLOOR OF THE BED SHALL BE CLEANED AND RAKED IN ORDER
TO LOOSEN SMEARED SECTIONS OF EXCAVATION.
• PLACEMENT OF AGGREGATE SHALL BE AS SHOWN, AND CARE SHALL
BE EXERCISED TO AVOID INCLUSION OF FINE GRAINED SOILS AND
WASTE MATERIAL IN THE ABSORPTION TRENCHES.
• THE PIPE AND STONE SHALL BE LAID AT THE GRADES INDICATED,
MAINTAINING STRAIGHT CONTINUOUS GRADES WITHOUT SAGS, HUMPS,
SEPARATED JOINTS, OR OTHER UNSUITABLE CONDITIONS
• ALL DISPOSAL FIELDS SHALL BE GRADED TO SHED RAINFALL AND
AWAY FROM THE DISPOSAL FIELD.
DIVERT SURFACE RUNOFF WA
•
DO NOT USE HEAVY EQUIPMENT WITHIN THE ABSORP77ON AREA
AFTER BED HAS BEEN INSTALLED.
•
THIS SYSTEM IS DESIGNED FOR WATER CONSERVING FIXTURES AND
OM IS NOT DESIGNED TO ACCOMMODATE EXTREME WATER USE OR
EXTREME ORGANIC LOADING DEVICES SUCH AS JACUZZI TYPE SPAS
0R GARBAGE GRINDERS. • F WA AND SURFACE TER DRAINAGE
NG GARAGE CELLAR A ROOF F001T
,
MUST BE EXCLUDED FROM THE WASTEWATER SYSTEM.
SYSTEM MATERIAL
SPECIFICATIONS
ABSORPTION BED AGGREGATE
STONE IS TO BE 3/4" TO 1-1/2" WASHED CRUSHED STONE.
EFFLUENT SEWER PIPE
PIPING TO BE 4" SDR-35 OR SCH-40 PVC. INSTALL WITH 1/8"
PER FOOT MINIMUM SLOPE.
FILTER FABRIC
FILTER FABRIC TO BE 4.8 OZ/SY NON—WMOVEN SEPARATION
FABRIC; TENCATE MIRAFI 14ON OR EQUIVALENT.
HOUSE SEWER PIPE
PIPING TO BE 4" SDR-35 OR SCHEDULE 40 PVC. INSTALL WITH
1/4" PER FOOT MINIMUM SLOPE.
TOPSOIL
PLACE 4" MINIMUM TOPSOIL OVER ENTIRE BACKFILL AREA.
SEED, MULCH, AND ESTABLISH TURF.
�P- Oe\-&�) - 202,3
TAX MAP # 309.18-1-46
ALTERATION OF THIS DOCUMENT EXCEPT BY A LICENSED PROFESSIONAL
ENGINEER IS A VIOLATION OF WS EDUCATION LAW.
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: 14 August 2023
To: Susan Bishop
(Applicant)
Re: System Inspection Site Report for:
68 Richardson St, 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 from14 August 2023, the date of the inspection.
Sincerely,
A
John O'Brien, Director
Budding & Codes Enforcement
Town of Queensbury
/kd Revised March 2022