PT-0472-2023 Property Transfer Sewage Disposal Information Form
Date: 6/12/23
Town of Queensbury
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net ; ,i
5E/A-OS
Luke G. and Jane M.-egyars QPRT JUL
(Name of Owner/Applicant) TOWN OF UE
BUILDING: 8 c r?r`':s
Re: Onsite Wastewater Treatment System Inspection Information Request --------
17 Heron Hollow Rd
(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$275 permit fee). The deposit is forfeited
if the owner fails to complete the repairs or,installation as stated above.
If you have any questions, please call.
Phone: (518) 761-8256 Email: kated@queensbury.net
Thank you.
Sincerely,
041/4,9116/4.*
John O'Brien, Director
Bu)ding and Code Enforcement
Town of Queensbury
Property Transfer Packet Revised July 2022
,•,,;;; � � � � ��, �2��3 Office Use Only
Permit#: Od172-2 0( + )3
Town of Qarcrnsbur} ss11 _J Fee:_$ o
742 Bay Road,Queensbury,NY 12804 TOWN Or QUEENSL�tURY Invoice#:`s _
P:518-761-8206 or 518-761-8205 BUILDING CODES
www.queensbury.net —L ~�-----------�
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: / 7 14.5-Ro/'r At I I o w go
Tax map number: 523400 227.17-4.1 22 4��--1—/ 4
Property owner: Sears pers. Residence Trust Luke Sears and Jane Sears
Mailing Address (c/s/z): 4 Paddington Circle Bronxville, NY 10708
Cell#: 917-375-1284 Land Line#: 718-542-2200
Email: (sears@Igssales.com
Applicant (if different than above):
Mailing Address (c/s/z):
Cell#: Land Line#:
Email:
❑ Proposed Owner ❑ Realtor ❑ Attorney El Other(explain: )
Septic Contractor:
Mailing Address (c/s/z):
Cell#: Land Line#:
Email:
Reason for Inspection Request:
❑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 5 # Bathrooms 8 # Kitchens 1 Jacuzzi tub(s) ° Garbage grinder
Onsite Wastewater Treatment System:
How many systems are on the property? I
Year system(s) installed: Tank Size of Septic Tank
Type of Absorption System:
Are all system components wholly within the property boundaries? ■❑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 ■❑ Date tank last pumped N/A ❑■
Frequency of pumping N/A ■❑
List known repairs/replacements, with dates: C 1 Va... _
Date Type of Repair/Replacement D �
TOWN OF QUL .IZBUF.Y
BUILDING &CODES
Operation:
System problems? ;i s ❑p No
• Sewage odors? El Yes ❑ 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? El 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: Luke G. Sears
Signature: q/KIL 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
rrIYO K Lake George
STATE Park Commission
KENNETH W. PARKER DAVE WICK
Chairman Executive Director . O2.\ -t�1„ n ^2_0�.
October 10, 2023 G.
LUKE &JANE SEARS
4 PADDINGTON CIRCLE
BRONXVILLE, NY 10708
Re: Wastewater Inspection, 08/15/2023
Parcel#: 227.17-1-4.1 Town of Queensbury
Address: 17 HERON HOLLOW RD, Queensbury NY
NOTICE OF COMPLIANT WASTEWATER SYSTEM
Mr. Sears,
Thank you for coordinating a wastewater inspection with the Lake George Park Commission.
The above-referenced inspection conducted at the subject property indicates that the wastewater system onsite is
designed and functioning in satisfactory compliance with applicable standards. Please maintain a copy of this letter
along with all other pertinent documents for the life of the wastewater system (e.g. pump out records, inspections,
repairs, permits).
The next wastewater inspection for this property will be due in 2028. In the interim, so as to prolong the proper
functioning of this system, please continue to employ best management practices in the use and maintenance of
your system. Resources concerning best management practices can be found on the Commission website:
http://Igpc.ny.gov/septic-systems
If you have any questions regarding the Commission's wastewater management program, please feel free to
review our online resources or reach out to the Commission office using the contact information below.
Thank you again for your consideration. Your interest and efforts to protect Lake George water quality through
effective wastewater management is sincerely appreciated.
Seth Landry
Engineer Technician II
Lake George Park Commission
PO Box 749, 75 Fort George Rd, Lake George, NY 12845
(518)668-9347 I fax (518) 668-5001
Techl@lgpc.state.ny.us
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PROPERTY TRANSFER SEWAGE DISPOSAL
V Satisfactory Compliance Notice per LGPC
Town of Qyccnsbury
Building&Codes Enforcement
742 Bay Road,Queensbury, NY 12804-5902
P: 518-761-8256 www.gueensbury.net
Date: 30 October 2023
To: Luke Sears
(Applicant)
Re: 17 Heron Hollow Rd, Town of Queensbury, NY
(Site Address)
As requested, the Town of Queensbury's Building and Code Enforcement Department
has reviewed the wastewater inspection letter provided by the Lake George Park Commission
(LGPC). Per their findings, all components have been found to be compliant.
Please be advised that, while the system seems to be functioning 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 from10 October 2023, the date of the LGPC
inspection.
Sincerely,
A
John O'Brien, Director
Budding & Codes Enforcement
Town of Queensbury
/kd 10/26/2023