PT-0656-2023 Property Transfer Sewage Disposal Information Form
Date: Pi 113 o v a
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Town of Queensbury
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net
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(Name of Owner/Applicant)
Re: Onsite Wastewater Treatment System Inspection Information Request for:
Y/ C_AN-Q-3V(Nj\-- ..—C30,t\-- -- 103jti(14-Al (2 . --- '
(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 $275 permit fee). The deposit is forfeited
if the owner fails to complete the repairs or installation as stated above.
If you have any questions, please call.
Phone: (518) 761-8256 Email: kated@queensbury.net
Thank you.
Ieceo
Sincerely, V" 7
(20/04,/k, OCT 162
423
/r"� BL AD/G&EEAis
CODESRY
John O'Brien, Director
Building and Code Enforcement
Town of Queensbury
Property Transfer Packet Revised July 2022
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1 �
Office Use Only
Permit#: —P14:25 2.023
Town ofG eteelsbusy Fee:_$ 2-4-5
742 Bay Road,Queensbury,NY 12804 (-4'
P:518-761-8206 or 518-761-8205 Invoice#:
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: 1 b C�
Tax map number: e 01/41/4.r �-� A \ 1
Property owner: g ,\--- C�-� � (Y\�'� -SL- j��v_'( -s \-W1 Cjet(A)CA'1)
Mailing Address (c/s/z): 3 'A 'CW 0 L-z;`!u v' ► 2-a ')(4
p
Cell #: (5l 8er.)
l ti• Pr‘ ` Land Line#: YL) I (,1\
Email: y i n(\\R-) C. n S € nrIG<\ s C-e)
Applicant (if different than above): A..,-2
Mailing Addre s (c/s/z): 3 1 UJ ; LW cook LA NA.-- Z)\)\,x-4"3\0 ) N 2 e 0\ll
Cell #:(51 19 z.--- '1 I Land Line#: S\ J �� k- \-4
Email: '� .,r`\� 3 C.�.n�� yC(\0 \\ CA)
❑.Proposed Owner ❑ Realtor ❑ Attorney they (explain: (---XR-G U/ /''
AOrk,
L n o \c.. rdliffitSA
Septic Contractor: S f) � 3`zw-Rr- �,44-"`� 0 \
1 �C
Mailing Address (c/s/z): L 0w-kp- \N cka--Q .
Cell#: Land Line#: (51 d ) 1
Email:
Reason for Inspection Request:
❑On the market ❑Future listing ❑Sale Pending eed Transfer [' Other:
Property Transfer Packet Revised July 2022
t
HOUSEHOLD INFORMATION. . _
**PLEASE SEE SEPARATE PAGE FOR EXEMPTIONS**
# Bedrooms S # Bathrooms \ # Kitchens. i Jacuzzi tub(s) O Garbage grinder 0
Onsite Wastewater Treatment System:
How many systems are on the property? ,I 01/4,3
vv\5
Year system(s) installed: Tank Size of Septic Tank / 0 ® 0
Type of Absorption System:
Are all system components wholly within the property boundaries? IN Yes El No
Are system plans available? ❑ Yes No
Does the system(s) serve multiple properties? El Yes No
If yes, describe
Maintenance:
Service agreement? El Yes o; If yes, business' name
Date of last inspection A, \ti N/A ❑ Date tank last pumped ,2 0 1,, 2 N/A ❑
a
Frequency of pumping N/A ❑
List known repairs/replacements, with dates:
Date Type of Repair/Replacement
P4
L\ 5�� o��� � .� . 5\mom-�.V w��
Operation:
System problems? ❑ Yes N
• Sewage odors? ❑ Yes fio
• Direct surface discharge(s)? ❑ Yes 124o
• Back-up of toilets? ❑ Yes DNo
• Back-up of any other fixtures? (e.g. slow drains) ❑ Yes r
• 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:
r'� �,
Affiliation: ❑owner ❑ agent ❑other: �1 C , Ik,
Please print name: \
Signature: V- C (cia' _ Date: /22--
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
,78ecE11 w,- i a,
OCT 1 Q
.0 r u 2023 a .
DUILD/NG 2"L'ivSBURY
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iV lii STANLEY T. GRANGER
Permanent Concrete Products
P.O. Box No. 2
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Hudson Falls, New York
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aGlens Falls 792-2924
Lake George 668-3396
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DBA CONDON'S SEPTIC SERVICE" " `� ....AO
2 Lower Warren Street • Queensbury, NY 12804 --( ; . ,` : :,,/:,
Phone: 518-798-8194 • Phone: 518-798-8542 • Fax: 518-798-3213 We take pride in everything we do!
NAM DATE CALLED DATE COMPLETED
I S P (—/ f 1, // ---
STREET , ` t JOB START TIME HOUSE BACKED UP
CS11-- t„T OYES ONO
W TON ! } �� j JOB END TIME GAL. TANK/UNCOVERED
11 SC)rre' b/\1 U"o c C..1�J "f' Q,�YES ONO
PHONE: HOME / WORK / CELL START TIME•SIZE TANK DEPTH TANK SIZE
.33 W- 0 a,1 /coo
CONTACT}�P�EFj ON END TIME•SIZE QUOTED PRICE ASEPTIC
J 611 O GREASE
DIRECTIONS ,
SEPTIC EVALUATION TANK: OK YES O' NO O OUTLET BAFFLE: OK YES EV NO O
TANK SIZE FIELD: OK YES O--" NO O INLET LI E -OK YES O`v NO O
LIQUID LEVEL: ; TANK CONSTRUCTION MATERIAL:
NORMAL O HIGH 0----• CONCRETE 01 PLASTIC O METAL O VENTS: L5 V j
ESTAGE OF SYSTEM: • EST VISIBLE AMOUNT OF LEACH LINES L�
TESTING OF INLET LINE: FLUSHED TOILET YES O� NO o �CT 16 2023
SEPTIC SYSTEM NOTES:_,,,
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SBURY
ii-`',a-"d',L - '.' :,•—rw y,• 4_.a�y;:�.Z;�2;• __ .ems "r 3: _ .'-r,01 �..:.:
• c �� � 'Y, -'DESCRIP.TION ,. _ '�. "• �
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PUMPING OF SEPTIC TANK: GALS. Q WO Q ( ' r C C
GREASE TRAP: GALS.
CLEANING LINES WITH SNAKE '
Pc1 ;c-1 (6 e C (< q - II f' g g
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WE WILL SEND YOU A REPUMP REMINDER IN 9 YEARS. SUB TOTAL /S'- r .
AUTHORIZED SIGNATURE
PROCESSING FEE
TERMS: A Late payment charge of 2%per mo.
shall be payable upon all unpaid balances over 30 days. Collection Costs, including reasonable TAX% n,t� 1 �j
Attorney Fees,will be charged to the Customer. There will be a$50.00 charge for all returned checks. TOTAL ( C7( 7 1 5
Method of Payment: O CASH O CREDIT CARD CHECK
Please charge tom (m MasterCardD Visa Card No:'-- Exp.Date
r
Signature: �'"i. (1-' w ,r •
PUMP IBS-1 Rev.06/11 W-Office Y-Customer
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: 31 October 2023
To: Lesley Conway
(Applicant)
Re: System Inspection Site Report for:
18 Chestnut Ln, 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 from23 October 2023, the date of the inspection.
Sincerely,
A
John O'Brien, Director
Budding & Codes Enforcement
Town of Queensbury
/kd Revised August 2023