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PT-0138-2023 ' Prope-ft�' DiitpcisalImfmrrhafi«7n Form, da Date: Town of 0—yeensbu' 742 Bay Road,Queensbury,NY12804 CX (1\i6e of Owner/Applicant) Re: Onsite Wastewater Treatment System Inspection Information Reque WF.),VVN OF OUEEINF*"-3 1 J RY Lt I (Site Address for inspection) Thank you for requesting an inspection for the mnsite wastewater treatment system (OWTS) located on the property referenced above. We look forward to completing a thorough inspection for you. You can help usdo 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 o 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 ofCiueensburV's fee for thisserviceis$275. 8e.advbed that all fees scheduling the inspection. We require 4@ hours notification prior to scheduling the inspection. |f the purchaser isrequesting an exemption, please submit this application along with anotarized 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$227G ($2OOO refundable deposit plus$Z7S permit fee). The deposit is forfeited if the owner fails to complete the repairs or installation as stated above. |f you have any questions, please call. Phone; (518)761-8256 Email: kated@queensbury.net Thankymu' S/ncereky, d ]o' n [/@rhen, Director Building and Code Enforcement Town ofC1ueensbury � Office Use Only Permit#: -01�)8-2023 rn,n i!'C`rcrnsbun Fee:_$ Z"�r., 742 Bay Road,Queensbury,NY 12804 P:518-761-8206 or 518-761-8205 Invoice#: ��� 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: 53 b11rc3n 9,oa(A , LaV;e- Gc-om e Ny lZB4rs Tax map number: 59,3+00 cl . 13 Property owner.: f]soyD nv— 6(Ay'. k-n Mailing Address (c/s/z): 3\DU 91X\J'y54t �)V' \I OoVt oLckx C�3 Cell #: R93 OOb Land Line#: '5\U - rl b\ - r1 r131 Email: Oka$\ouq�� oyo\ Wean Applicant (if different than above): Mailing Address (c/s/z): Cell #: Land Line#: Email: ): ❑ Proposed Owner ❑ Realtor ❑ Attorney ❑ Other (explain: ) Septic Contractor: ©YYmn ��a G%C.0tJCNT%0' Y1 * Mailing Address (c/s/z): \c�► o (tea Cell #: 11 ►YSe� �Land1 Line#: 511$ - rl°l 3 - aago Email: VV\0Ynina5' ow e CA M Reason for Inspection Request: ❑On the market ❑ Future listing ❑Sale Pending ZDeed Transfer ❑ Other: "�rc�v►s�er -}o w.-i `rcvocPMe;A- LA-S� for e5�� Property Transfer Packet Revised July 2022 HOUSEHOLD INFORMATION "PLEASE SEE SEPARATE PAGE FOR EXEMPTIONS" # Bedrooms -4 # Bathrooms a # Kitchens Jacuzzi tub(s) 0 Garbage grinder l ►4, e V+ffC 3 buk W-r— rrOAe 'Does nod w0r►G1 vV C_ c\o ov\e kvl�o a sw►a\1 ones nok use- Onsite Wastewater Treatment System: How many systems are on the property? l p -kt,��k Year system(s) installed: TankY-koyJ Size of Septic Tank jppgjjype of Absorption System: Vo nok Y-n-*J Are all system components wholly within the property boundaries? Eyes ❑ No Are system plans available? ❑ Yes ❑ No onk l �tie� 3 �ouncA CSC-e- Does the system(s) serve multiple properties? ❑ Yes ❑ No If yes, describe ): woA Soxj NO ,AAvexc ho►.S �01C� gOt- 3U y;�!cxV S Cwlcd i s NOT A s-e a . Maintenance: Service agreement? ❑ Yes 9No; If yes, business' name Date of last inspection 'I I h -IoZA N/A ❑ Date tank last pumped 1 11 62A N/A ❑ Frequency of pumping N/A ❑ everq "uplecA 63� �jeo*-s 1 �in� 60>Me- ts 0V'11'� used two *o }kre-c \W.,_&s CX dray Or viav°`-v List known repairs/replacements, with dates: ckk1 Date Type of Repair/Replacement 1 01 7 R� ba\� eahe� out CSGC -%A",e do Operation: System problems? ❑ Yes No Sewage odors? ❑ Yes No Direct surface discharge(s)? ❑ Yes ❑ No Back-up of toilets? ❑ Yes E�No AAmi' "nieo"s Back-up of any other fixtures? (e.g. slow drains) ❑ Yes d 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 ❑agent ❑other: Please print name: 1 0�. E. Sarb�lrrl Signature: ��) Date: 22 2az3 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 j:,,-j, 59 Blanchard Road Lou DeRidder, Pres. Giansevoort, NY 12831-2154 Phone#518-793-2290 fi 1 IT, -P AVAT 0 ON SEP70C mor ningstarseptic@hotmaii.com Fax#518-793-2115 Date: .7 TO: No. j , Phone NumbeK AMR, 0 3 2023 scf INVOICE: Terms: Paym6nt 11'Abice I Septic Pumping if 1( Gallons at-- per Thousand Grease Pumping Gallons at per Thousand Digging to Expose. Septic cover at per Half Hour .......................... After Hours or' Weekend Emergency Call -! per Half Hour ......... .............. Septic Inspection....................I ....Level ...L.ev.el...I........Lev I el..2 ...Lev.el--3............... .. .... .. . ....... ... .. ...... ... SewerJetting ............................................................................................................. Materials ..................................................................................................................... SepticLabor.................................... ............................................................ ......... ServiceCall .................................................. .................................. Q, Subtotal Sales Tax Please note a$50.00 processing fee Will be charged for any checks returned by the bank for non-sufficient funds(NSF checks). Total Technician MORNING STAR EXCAVATING, INC. ,& SEPTIC SERVICE 107 Jewell Road Frank Shaw, Pres. Gansevoort,,NY 1128a1-211'54 Fax# 51.8-.793-2 115 Date:, c/- 7-/6 ri�s AM, 3 fMNNK! 0, LAI Phone > . NuMber 7 o INVOICE: Terms: Payment Due Upon Receipt of Invoice 1 1/2% Interest After 30 Days Se tic Pumping ballons at per Thousand , Grease,Putping Gallon's at per Thousand Digging to Expose Septic cover of per Half Hour ....................... After Hours ..or Weekend Emergency Call per Half Hour .......................... SepticInspection........................................................................................................ SewerJetting ............................................... ...................;................... ...... Materials ............................................................... ............................................ Other- rbcf C C Subtotal ° ..fir"/� � +� j• _.. Sales",Tax Total Technician �nh APR 0 3 t�{ _.' `. 1 �4 E I IN f T fr �J Parameter List. ------------ Copy tab: ----------------- Color/B&W: Type of original: Method: Lightness: Saturation: Red. Green: Blue: Black level: White level: Sharpen: Blur: Input size: Width: Height: Auto Width: Auto Length Output size: Width: Height: Auto Width: Auto Length Scale- Ualue: WM�� i'v NEW SEPTIC TANK TO BE CONNECTED TO VUSTING DRYWELL IN PARKING AREA PROPOSED IV PVC SDR-3S EFFLUENT SEWER, r PER FOOT MINIMUM SLOPE MaMNG METAL SEPTIC TANK Lands IF of TO BE REMOVED & REPLACED McPhillips Family Trust 289.13-1-25 Lands NIF of wo—posati'low GAL SINGLE PROPOSED 4w PVC SDR-35 David McGowan COMPARTMENT PRECAST GMAGE SEM& to PER 289-13-1-34 CONCRETE SEPTICTANK FOOT MINIMUM SLOPE NOTE-. NO WELLS ARE VISIBLE WrMIN 50-FT OF PROPOSED SEPTIC TANK FOR GUM COTTAGE G D Lands NIF of CA 100,Z Kenneth Searles GARAGE j 289.13-1-29 GUEST rajids of Daphne D. Sanborn COTTAGE WASTEWATER Lands NIF of 'NFO FROM Daviowan d McG 289.13-1-31 PLAN REFERENCE i. 0.27 Acres 289.13-1-30 < I Ir— I SHED 44�Nc I ' / ­1 0 fif -1 Z / / �i DECK 00TIM _01' NEIGHBORING RESIDENCE SM4 CK 3-BEDROOM HOUSE pasr.(NG WELL* uas,nnG i"TAN'K Lands NIF of AND "FLUIENT PUMP AA^o%,4^# ne OU-410" 289,13-1-32 DISTING GRINDER DECK PUMP TO REMAIN �V Lands IF of Gerald Dineen 14/ 289.13-1-33 Lands NIF of Peter Dineen .289.13-1-57 PLAN REFERENCE. 1. WASTEWATER LOCATION FOR LANDS NIF OF KENNETH SEARLES FROM "WASTEWATER REPLACEMENT SYSTEM PLAN PREPARED FOR KENNETH AND LEIGH SEARLES," DATED NOVEMBER 6, 2018. LAST REWSED DECEMBER 17, 2018. PREPARED By HUTCHINS ENGINEERING. PERMIT NUMBER. SEP07202018. MAP REFERENCE: BASE MAP INFORMATION FROM WARREN COUNTY GIS, AERIAL, PHOTOGRAPHY, AND FIELD MEASUREMENTS. THIS IS NOT A FED SURVEY. ALL LOCATIONS ARE APPROMATE CONTRACTOR TO FIELD VERIFY ALL SETBACKS PRIOR TO BEGWMWG INSTALLATION. CONTRACTOR To nELo VMFY LOCATIONS AND &STANCES W IS 991 A FELD SURVEY. WASTEWATER SYSTEM SETBACK REQUIREMENTS PROPFJ? HOUSE 2.a LAKE IV WATER SUPPLY UK U-NE SEPTIC TAW 10' 10, 50' 50' 10' ABsoRP77oN FIELD lot 20' I 100' 100' i 10, 2023-09-29 13:04:00 ------------------------ _-------- tab: Setup tab: B&W Margins Printer: HP DesignJet T1790 Scanner: HP SD Pro 44-in Scanner (IP) CAD B&&W Top: O.Ocm Windows driver: Units of measure: Centimeters A &&W Threshold Bottom: 0-0cm HP DesignJet T1700dr PostScript Load: Center .1 Left: O.Ocn Printer profile: HP DesignJet T1700 About Right: 0.0cm Unprintable Area Product name: HP Scanner System Use Unprn. Area: Yes Top: 0.5cn Product version: 7.14 0 Print paper border: No Bottom: @.Scn Build: Build 95395 0 Print Quality: Left: U.Scn Component build: 95395 0 Scan DPI: 300 dpi Right: @.Scn Scanner nodel: HP So Pro 44-in Scanner (IP,, 255 PrintPrinter 300 dui Media width: 91.4cn Scanner firnware version:3-2-2-011 Off Ink Pr Original: DPI: Yes Media profile: 1100 Scanner firmware date: Nov 08 201712:35:45 0 Enhance Gray: No Roll: Auto Auto Descreening: NO Account: 90-lcm Layout: mot -Mal Scan jobs: 43.3cm Tiling / Paneling Print jobs: Yes Glue marks: No Copy jobs: Yes Width: 76-2cn Scan area: Auto Length: 127-0cm Print area: 90.1cm Overlap: 1.3cm Paper area: 43 .3cm Nesting Total Account: Total Yes optimized: No Scan jobs: 9010 Yes Spacing: 1.3cm Print jobs: 3 100% Copy jobs: 23 100.0 % Scan area: 3941.8888 sq.pi Print area: 9.8740 sq.n ---------------------------- -------------------------------------------------------------------------------------------------------------------------------------- Paper area: 12.0584 sq.n -------------------------------------------- LLAKE i�ATER SUPPLY Septic Tank Reviacenvent Plan lot -- 20' Is qr@ghic Scale 20 0 10 20 40 80 114" PER FOOT MIN. SLOPE _4��PVC SCH-4-0 p) JUL W&I OF E3UILDIN1 UeE[VS[3'1a'1' SUGGESTM., POLYETHYLENE EXTENSION TO GRADE WTH TAMPER RESISTANT ACCESS COVER (NON-7RAFFIC AREAS) 12" MIN. COVER 1180 PER FOOT MIN. I SLOPE 4' PVC SCH-40 EFFLUENT SEWER TO EXIST DR"ELL WATERTIGHT SLEEVE 160 & SEAL (TYR) 40 PVC TEE INLET BAFFLE LIQUID DEPTH JO* MIN. 60" MAX MINIMUM 2X MDTH MAXIMUM 4X MD774 0 PROPOSED 1OOC GALLON PRECAST CONCRETE SEPTIC TANK �qtic Tank Detail NTS T OWN OF QUEEINSBURY BUILDING DEPARTMENT Based on our limited examination, compliance. with our comments shall not be construed as indicating the plans and specifications are in full compliance with the Building Codes of New York State. 289.13-1-31 SEP-0448-2023 Sanborn, Daphne 53 Birch Rd Septic Alteration -- tank only rN D19 IFISafely. NeWPAYork iii Call Before You Dig H WAR The Required Time E Confirm Utility Response N Respect Tim Marks 0 Dig Wift Care 800-962-7962 ISSUED FOR PERMIT 71191202J vnimt.diventolynetwyork.com lam' Date SEPTIC TANK REPLACEMENT PLAN prepared for. Daphne D. Sanbom 53 Birch Road Town of Queensbury, County of WarTen, State of New York • Drawn: HK8 Checked: LKV--. Scale: NOTED, Date: 6 1212023 169 HaWitand Road IF Queensbury, NY 12804 11 292169-01 (518) 745-0307 Phone Hutchins En ineering PLLC (518) 9 745— 0308 Fox 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: 4 October 2023 To: Daphne Sanborn (Applicant) Re: System Inspection Site Report for: 53 Birch 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 five (5) years from9/28/2023, the date of the inspection. Sincerely, A John O'Brien, Director Budding & Codes Enforcement Town of Queensbury /kd Revised August 2023