PT-0586-2022 - Property Transfer Sewage Disposal Information Form
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Town of Queensbury
742 Bay Road,Queensbury,NY 12804 '� -- ._
P:518-761-8256 www.queensbury.net D CE 1 v Eo----
Daniel Slote SEP f0
(Name of Owner/Applicant) Z0ZZ
Re: Onsite Wastewater Treatment System Inspection Information Requ T BUILDIWN NQ EENsBURy
OOpES
20 Burnt Ridge Rd Queensbury
(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$275 permit.fee). The deposit is forfeited
if the owner fails to complete the repairs or installation as stated above.
If you have any questions, please call.
Phone: (518)761-8256 Email: kated@queensbury.net
Thank you.
Sincerely,
Violtkt;1^-/
Johri O'Brien, Director
Bt 9ding and Code Enforcement
Town of Queensbury
i
Property Transfer Packet Revised July 2022
Office Use Only
Permit#: EnEke_•
O2Z
Timm of QLccnsbury Fee:_$ 2.`3.0 04-2-jod t'Z
742 Bay Road,Queensbury,NY 12804
P:518-761-8206 or 518-761-8205 Invoice#: Z� 56 ty
www.queensbury.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: 20 Burnt Ridge Rd Queensbury
Tax map number: 239.16-1-19
Property owner: Lynn & Daniel Slote D ( Q
17 Colonial Gm Loudonville NY 12211
Mailing Address (c/s/z): SEP 1 9
Cell#: 518-322-9752 Land Line#: Same 2022
Email: dslote@naiplatform.com T BUJ/OWN o�QUeFNSB
URY
Applicant (if different than above): Same
Mailing Address (c/s/z):
Cell#: Land Line#:
Email:
❑ Proposed Owner ❑ Realtor ❑ Attorney ❑ Other(explain:
Septic Contractor: Cooks
Mailing Address (c/s/z):
Cell #: Land Line#:
Email:
Reason for Inspection Request:
1
❑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 2 # Kitchens 1 Jacuzzi tub(s)0 Garbage grinder 0
Onsite Wastewater Treatment System:
How many systems are on the property? I
Year system(s) installed: Tank UNK Size of Septic Tank 400+
Type of Absorption System: Leech
Are all system components wholly within the property boundaries? ❑U Yes ❑ No
Are system plans available? ❑ Yes 0 No
Does the system(s) serve multiple properties? ❑ Yes 0 No
If yes, describe
Maintenance:
Service agreement? ❑ Yes 0 No; If yes, business' name Cooks
Date of last inspection 5 years N/A❑ Date tank last pumped 08/06 N/A ❑
Frequency of pumping monthly N/A ❑
List known repairs/replacements, with dates:
Date Type of Repair/Replacement
pumped evry 3-4 weeks in the Summer
/I a- P 0,44
V,1-9 ke a...) — Zoo
Operation:
System problems? ❑ Yes 0 No
• Sewage odors? ❑ Yes ❑i No
• Direct surface discharge(s)? ❑ Yes [M No
• Back-up of toilets? LI Yes (I No
• Back-up of any other fixtures? (e.g. slow drains) ❑ Yes gy No
• Seasonal ponding or breakout of leach field? ❑ Yes Kg 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: ❑t owner agent . p other:
Please print name: Daniel Slote
Signature: Date: ",46/0a"
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. 9 —3�Oi t )/1' fat4 4, :'w 4 Suk
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
J 05o(Q,219'Z2_
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.
IN 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 1st 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
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: 53rowner ['agent ['other:
Please print name:
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 July 2022
John O'Brien 11/29/2022
CC:Charles Dyer
Town of Queensbury Codes and Enforcement
742 Bay Rd Queensbury NY 12804
John thank you for your help yesterday with regards to our winter waiver and septic application help.
We have hired Tony Abrantes (Cutting Edge/Cuttingedge-group.com)to install our new system and
Conner Demeyer at EDP along with Dennis have done the design work.Tony is finalizing his numbers
and believes he will be able to get some of the system done this winter to include the field and tank
installation.The trenching for then trace line and grinder pump will have to wait until early Spring for
completion of the system.Once Tony has the permit and has installed the field and tanks,we will make
sure to reach out to you or Charles to inspect the to date completed work.
My cell is the best way to reach me if you have any questions.518-322-9752
•
Best
/4/ ///•:;242 c;--6 c'=)(
Daniel Slote •
20 Burnt Ridge Rd PID#(239.16-1-19)
Queensbury NY
-ryt0,p O�Q�J P
JAMES D.VERRO
No ary Public,State of New York
Qualified in Columbia County
01VE5036952
My Commission Expires Dec. 12.c702
900 Route 146 Clifton Park, NY 12065
(P) 518.371.7621 (F) 518.371.9540 edpllp.com
September 26, 2023
Town of Queensbury Building & Codes
742 Bay Road
Queensbury, NY 12804
Attn: John O’Brien, Director
Re: Slote Residence – 20 Burnt Ridge Road
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:
WASTEWATER REPLACEMENT SYSTEM FOR THE SLOTE RESIDENCE
20 Burnt Ridge Road, Town of Queensbury
October 12, 2022
Sheet 1- Wastewater Plan
Sheet 2- Wastewater Details
During the course of construction Environmental Design Partnership LLP was on the job site to observe key
components of the system installation including; 1,250 plastic septic tank, 1,000 gallon plastic pump tank,
simplex pump, raised 12” thick stone absorption bed on August 23rd of 2023. I have provided an ‘as-built’
plan which indicates the system component locations, in accordance with the approved Town plans.
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,
Connor DeMyer, Project Engineer.
Attachment
Cc: Daniel Slote dslote@naiplatform.com
Sean Freeman freeman@mosscap.com
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