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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.
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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
------------------------
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Paper area:
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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