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PT-0794-2023 Property Transfer Sewage Disposal Information Form 461111iii Town of Cuccnsbury 742 Bay Road,Queensbury,NY 12804 Date: _ P:518-761-8256 www.queensbury.net it?O kh i vr5 YLOJN (Name of Applicant) Re: Onsite Wastewater Treatment System Inspection Information Request for: 511 R 0�\ �js e\- • (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 scheduling an inspection with the Town of Queensbury, we require the following: • this completed application • a site map indicating the location of the septic components • the pre-inspection preparation (see the last page of this packet) is completed prior to our arrival • the appropriate fee(s) are paid: $275.00 (an additional $2000.00 refundable deposit, if you are requesting a waiver) • the appointment date/time that your septic hauler is scheduled to pump out your tank. We require 48 hours notification prior to scheduling our inspection. If an exemption is requested, 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) • the map locating the septic system • payment totaling$2275($2000 refundable deposit plus-$275 permit fee). The deposit is forfeited if the owner fails to complete the repairs or installation as stated above. If you have any questions, please call. Phone: (518) 761-8256 Email: kated@queensbury.net Thank you. Sincerely,wfr, John O'Brien, Director BU)ding and Code Enforcement Town of Queensbury Property Transfer Packet Revised September 2023 Office Use Only Permit#: r— d -20 23 Town of Quccn,bury Fee:_$ 9. — 742 Bay Road,Queensbury,NY 12804 " P:518-761-8206 or 518-761-8205 Invoice#: 6Oa) www.queensbury.net I 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: SL1 Re)c)‹ke14 Tax map number: 5-').-5 YOtO 7„ ��" �LlI pvf✓ �' Current owner: L.- 6-, L Mailing Address (c/s/z): Pp � OFmw�u Ei Bupy Cell #: I � �f Z ©av Land Line#: 05) Co5"-G`" get 5 , Email: 1 �,-, 1C\c-SV,c3v1 �l 1���51��(l� �,�� .CA) Applicant (if different than above): -15-cfc , K:JS Acc/\, Mailing Address (c/s/z): IFC� S� _/ jc 1`dc�-r' _ F, \Zg ° Cell#: (ct ) qZS-j C x Land Line#: Email: Irc-)".AK:S5Var.C � �CiSsn .e r��e'TS o GcOt,v.. ❑ Proposed Owner ❑ Realtor ❑ Attorney Other (explain: fiO4I ouAA- ) Septic Contractor: ND Se_v-) '{_ Mailing Address (c/s/z): Cell #:(57<S)(0Z"5- ' ,HS-3 Land Line#: (cteci i f--a 491 Email: 40 !OE' 1� Q Xa100,640wA Reason for Inspection Request: f•_I On the market ❑ Future listing ❑Sale Pending ❑ Deed Transfer ❑Other: Property Transfer Packet Revised September 2023 HOUSEHOLD INFORMATION **PLEASE SEE SEPARATE PAGE FOR EXEMPTIONS** # Bedrooms q # Bathrooms # Kitchens f Jacuzzi tub(s) I Garbage grinder 0 Onsite Wastewater Treatment System: How many systems are on the property? Year system(s) installed: Tank UCH Size of Septic Tank O r'.Type of Absorption System: Are all system components wholly within the property boundaries? ®Yes ❑ No Are system plans available? AS Yes ❑ No Does the system(s) serve multiple properties? ❑ Yes ® No If yes, describe ): Maintenance: • Service agreement? ® Yes ❑ No; If yes, business' name k C.0kJ" 3t«� Date of last inspection N/A El- Date tank last pumped 7//51Z3 N/A ❑ Frequency of pumping 'a, ,I,a.gc N/A ❑ List known repairs/replacements, with dates: Date Type of Repair/Replacement Operation: System problems? ❑ Yes 1 No • Sewage odors? ❑ Yes E No • Direct surface discharge(s)? ❑ Yes ® No • Back-up of toilets? ❑ Yes ® No • Back-up of any other fixtures? (e.g. slow drains) ❑ Yes g No • Seasonal ponding or breakout of leach field? ❑ Yes ® No Property Transfer Packet Revised September 2023 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 one (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: ❑ attorney ❑agent* ®other (specify): �.,�\ o�ve.cr Please print name: Signature: �_,. � Date: /ZA43 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. *see Agent Authorization signature page Property Transfer Packet Revised September 2023 G,A7cE C/EoRGE I i r 1 I ' DBCD wA,1R SNIPPET LINE. ,, v WASTEWATER SYSTEM DESIGN SYSTEM INSTALLATION NOTES %as FVFe ,'COPPER WaIER SVPRY ONE:W� POPE%1EN510N� R BEDROOM RESIDENCE CONSTRUCTION SHALL BE AS SHOWN ON THIS BRAVING AND IN DISINFECTION AND WATER 1 FILTRATION i0 BE PROVIDED 1 \ DATER SAVINGFIXTURESDIVIDUAL DESIGN FLOW- 10GP/B OONupx100000H SH.CRITERIA MAN.FAUCETS) ACCORDANCE WITH HOUSEHOLD OUSEH0.SYSTEMSHE N ANDYS.ASTM MI NSTALUTIONNT OF ETH OF(THERMOPLASTIC t SYSTEM DESIGN FLOW-440 GPD PIPE SAND CORRUGATED TUBING IN SEPTIC TANK LEACH FIELDS , SEPTIC TANK 1250 WL PUMP PUYP STATION GAL-1000 l Ru DESIGN UTILIZES EN CORPORATION TYPE B IN-DRAIN GEOtEX11LE LEACH FIELD W EL. -DRAIN TYPE B GEOTE%TILE SAND FILTER UNITS FILTER UNITS INSTALLED N TRENCH CONFIGURATION INSTALLATION DES.PERCOLATION RATE IN ILL MATERIAL=1-5 M SH IN/1N ORC BE IN ACCORDANCE MTH THIS DRAWING,NYS DEPARTMENT OF ABSORPTION RATE-12 OPO/SF HEALTH REWIREMENTS.AND MANUFACMRERS INSTRUCTIONS ABSORPTION BED REONRED.362 Y ALL DISPOSAL FIELDS SMALL BE GRADED TO 91ED RAINFALL AND DIVERT E I L J ELFN N DRAIN TWEAB UNITS PROVIDE 6 SF/LF SURFACE RUNOFF AWAY ERNA THE DISPOSAL F.D. IN-DRAIN TYPE B TRENCH REQUIRED EACH�, PER SUgR CI.1 E AN USE 16 ELJEN IN DRAIN TYPE B UNITS(' UNIT) NOT USE HEAVY EQUIPMENT WITHIN THE ABSORPTION AREA AFTER • 223Y /� L'EY I•E9PEM, „IC. USE 2 TRENCHES AT 30 LONG(B UNITS EACH TRENCH) IN-DRAIN UNITS HAVE BEEN INSTALLED RFRAENCE _ 64 LF TOTAL 10 BE PROVIDED POTABLE WATER.PPLY TO BE LAKE GEDRGE LAKE WATER WTH ABSORPTION TRENCH NOTES ----1 � — FILTRATION AND UV DISINFECTION THIS DESIGN UTILIZES ELJEN"INDRAIN MI.B GEOBE%TILE SAND FILTER UNITS ,":,,, _ --_,, ,,a ,::: __,, . 41- 1i J MIN.SEPARATION FROM SEPTIC TANK TO LAKE•SO. INSTALLED IN A TRENCH CONFIGURATION REMOVE EYDOER ASPHALT IN THE 324 _CD_ 514•01'gTµ gBp9' \ MIN.SEPARATION FROM ABSORPTIOx MELO i0 LAKE=100 AREA OF THE PROPOSED ABSORPTION FIELD AN AREA 12'ODE BY 1'DECP /�S (RELINE ONLY) "'- IS TO BE EXCAVATED OVER THE ENTIRE LENGTH OF THE ABSORPTION s/ ��� / �' SITE SOILS DATA IRCNCHCS AND BACKFILLED WITH CLEAN SYSTEM FILL USE TRACKED '�--�_ 1^, • EQUIPMENT FOR ALL WORK IN ABSOPRTION FIELD AREA ABSORPTION u6 • / - \\ 1 TP1-10/31/OS BY T HUTCHIxS TRENCHES i0 BE EXCAVATED IN STABILIZED SYSTEM FRL ABSORPTION TRENCHES TO BE BOTTOM K TRENCH(BDTTBM OF CONCRETE SAND)TO BE \ RB'- ASPHALT INSTpl3FD AT ZS-01'BELOW EXISTING GFAOE. —_� •s \ 2-A' CRUSHED STONE J NOUN 1 �� 4-12. GRA.I.PA LOAM FILL MATERIAL NOTES L 12-zz'SLT LOAM L AFTER EXCAVATION OF INCONSISTENT NAIVE SOILS OVER THE AREAS SPECIFIED, ri5 BAAFILL EXCAVATED AREA MTH SYSTEM FILL MATERIAL. SYSTEM FILL TO BE �� \0 2J 2z-AB'SLIT[L4 ND FILL WITH IN-NICE PERCOLATION RATE OF 3-5 MINUTES. FILL O Q,)EA''y11�/-_�J1\ DRY OENTREASON L HIGH OF Pn TOABE STABILIZED IN 6'LIFTS TO MEET EXISTING GRADE _ V B NO SEASONAL FILL OIL THRO GHO T ENTIRE !I�I INCONSISTENT FRL SOIL THROUGHOUT ENTIRE DEPTH OF LEST PIT EROSION&SEDIMENT CONTROL NOTES -F� 'I�I I I� \ BFRNNiIOn TEST 1FARBEFORE ANT CLEANING OR GRUBBING OF,HE SITE IS INITIATED,AND OUTING PHASES.SEDIMENT TRAPS SHALL BE CONSTRUCTED IN aLL STORM • $ Q \ E, 226 Ltd].-1U/12/05 BY T.HUTCHINS SWALES AND DITCHES AND AS INDICATED ON THE PUN e-DEPTH 2.SEDIMENT ST OF HAT BALES PLACED TO FORM A 04 V.0 L--- SILT LOAM 2,SOME GRAVEL FILL PERVIOUS BARRERSw�THE Sw4[OR DITCH. •w --- 7 STABILIZED PERCOLATION RATE=2 MIN/IN ] j ''-v-�\\— _+ • 2 D.AT LEAST Two WOODEN IN METAL STAKES SHALL BE W F EN THROUGH EACH BPIF i0 ANCHOR IT In PUCE,COLJv[unONu SNOW FENCING uaY BE (♦J HO y USED IN MEU OF STAKES TO B,ABNZE BALE ME SEDIMENT TRAPS 4,F,3 i• 4.AFTER EVERY STORM EACH SEDIMENT TRAP SHALL BE INSPECTED FOR •FAILURES OR CLOGGING,AND ANY FARE OR CIDGGNG SHALL BE C �_ AL IMMEDIATELY CORRECTED. FL . a 5.ALL BARE EARTH AREAS$MALL BE SEEDED AND MULCHED AS SOON BE IS POSSIBLE TO PREVENT EROSION,AND EVERY BARE EARTH AREA SMALL BE SEEDED AND MULCHED AS SOON a5 PRACTICAL TEMPORARY RAPID WDWTH _ COVER CROPS,91CH AS ANNUAL MORASS MAY BE USED FOR TEMPORARY `' �3wEP t/9 PPER FLSUIN SURFACE STABILIZATION LIS S OPE iA- 6 SMALL BENCHES AND TEMPORARY INTERCEPTOR DITWES.INCORPORATING OFOIMENT COVER GAPS SHALL BE RE PILL AREA wAREE LING SLOPES ARE STRIPPED GAPS,S.SHALL BE CO STR AREAS ARE EXTENSIVE. SLOPES v1 DISTRIBUTION BOX h •71 Z,NEW SWILLS AND UNLINED DITCHES SHALL INCORPORATE MATING OR �i• ), I I,,." - J. / r NETTING OVER SEED AND MULCI1 WHEN THE INVERT SLOPE EXCEEDS 216 ALL CONIrp SEPTIC 1 NO UNLINED DITCHES SHALL BE SEEDED WITH REED-CANARY CRASS L+9 \ �� [ xKF: ORE OUR(A)FEET EITHER SIDE OF,HE SCALE OR DITCH CENEEAUNE,AT A Fr' ` �t0 A RATE OF25 POUNDS per ACRE AFTER JUNE,ALL SEEDED AREAS SHALL BE E� ER%ISTING CONCRETE \ONCRIIE PR P STATION MULCHED MTH STRAIN IMMEDIATELY. EialUINO WALL 00 .' J( Y 8.THE CONTRACTOR.ALL COUP,WITH THE NEW M.GUNElMES FOR IO' FSIETV - EN LAXE . O O I0 OI • URBANERTER OF THE SOIL SEDIMENT CO ROL AS PUBTI.SHEDBY THE NONE STATE •PROPOSED CURB-......‘,.,.. K -•'1-r JE LOUSE 8E185.__-1 - \� • �E�IP-1 W— 1 fORCEAN2iIyNPVC \ 4Nf�AECH3 NO9'Z.,3861' / \ yy. `� NI2=p855'E 59.w PROPOSED ELF.IN-DRAIN TYPE / lC• B SAND FILTER SETTS,(z) - O TRENCHES ]Y EACH ROCKHURST ROADW OW ALTERATION OF NONE[RG 0 AA VDE1NTWNCOF NYS EORGTON NWFESLOHLL WASTEWATER PLAN-RECORD DRAWING SCALE:1 ,D • RECORD DRAWING 12/19/2(06 0 ISSUED FOR APPROVAL 12/6/200S 110 PeV1910r1D Dote WASTEWATER PLAN prepared for • Stephen Kirshon MAP REFERENCE 89Rockhuist PROPERTY LINES, BOUNDARY INFORMATION Tem of QASWMRT,Warren Coln,Sew TAG AND MEAN HIGH WATER LOCATION FROM U•e.n Lw Ideckea GIM I erre A o I ea,• U/s/o5 'ACTUAL FOUNDATION LOCATION'GATED16, nd Rood MARCH 10,2005.LAST REVISED MARCH OueenanuP rY.NY 12804 20,2006,PREPARED BY ZAREN (516)245-030 Plume 291 3t-02-CJ1 A LTOUNIAN.LLS,LOUDONVILLE.NY Hutchins Engineering (TIN)TAn-owe Fp. �EOE I i I I rum.�ren� i I I i t OD.ramAnw TO¢rRarmm DOD.. . I MORO.CATER SYSTEM DESIGN SYSTEM INSTA I WATER UV. LLATION NO ` I o `o�T no:sr out.rum:.sn au war T...s�uu BE AS�oawnn w--umw I ) I ) DE.v9r m0 -moon aalwA warn AooSImANa rTR Tyr N.r Axnawr m .' ( NOUsrmn SnTurs MN rTuu. . jI I j I Nam StA _ro�Cy. nor ow mnnn MEMO w WAN Aiwa r ���' I i I F0D▪ r�'w-DRAIN TONE 0:mmnc Sum n.Was. SAND RUIN URNS MNAUW N nw TES 0 IN-DRAM aro Of u'."ius+ ) ,)qH �H...757, a I i l_____J i I na DEN RATE. uFamEa so,TIN RAIL IN FIll. rsu-r e REALM %ODOM WOAD OE IN A�wo yINUTM.MS DRAM,MS v MENEN n�^�* a' ' a▪ -aur TTrs D Lars Nmyq D WAR wsLlmDw9 I da•^, 'Dr, I e02 ve mi w-aux TOT a UN EL.N-DRAN inn.el ITS N.REWIRED 'uuAa s�°'°rr�""Ar rnw easrns i rnn wi um rawer II�r�r/�f�� *Vale, I w 2 ro'ru°o�' 1. (a wars EA.+tea) D NOT USE WAVE r N.NE Aemrsnw AR.urzR +..� t�_ y ��5 -Cnux Lars NATE DU:vsuum. i'.. ,,,. ."---'," ` MO,..- FUR.. sum, LAWNAM UN. ABSORPTIONNOTES • II • c. ..... MUKmDRA01 in, VE 0%nc sum rAri ZS i • SOILS rm�ot ArmvA1O u'km a Tic Aesa�`wnwr w� . /\ j, " +1: \\ eALaum rx raw+mm rzi usE !, 7 W.,-"o/a�M BY r xyrows EuwVwr FOR ALL KM w A95ooanax rmn AREA A raw .�'n o-.MwLSwIKr THERMS m a EXCAVATED w SUMMED SSRN FILL. ADswrTpN TawCICS 10 BE BOTTOM Cr TREND.(BOTTw,a CONCRETE Sum)TO BE - \`` ?-• CRU9IEy STONE MTN.AT ES-SI'BELOIT m02m.O GRADE VP .-Ir GRAVEL ru 0 / 1N \� Tz-zz•SU LOAD FILL MATERIAL NOTES Y� `) zz-.r mx cur EDAM ArTm mrAVA arimr�wcum NAME me �I,�I'�� ` Moo laCAyATED AREA Ta SONS D.rn mlui sEo „ 1 T a^'°^�xrm a rrr nE Tam w-r srsm nE MATERIAL. FILL TO p . j., Q� 7��/ T_ NO YASONAL MiW IANEL PLACE rrxCMnO!RAIL a]-S ImN ON '} 4 .y};i'�T•.'�i'1;::,?�;': b./ ` STEM,"u m.nIXW pl,a RPrn or TEST Nr 1p HE srlmWlIID w e•LIs,m MEET Easwc GU➢E. IEs nu. , sr,•.:; 4 a.:_ •'�� \ j� ON&SEDIMENT r:.}. +':: � ` PC- CONTROL NOTES • ,yi•.• .•.'•.•"••ti'•• ! .• \ a/Tz/os BY r.mrTETmrs ELM.m GROW m a IRE 9TE rs eonATm.um Wm 15Mr DEVIR TM°°r s uuaa,:r'RAPS SHAD.BE !... � '� '�•rr`s" �tcat.jli/,••'�.'�': mr EDAr n salE su A.Aw DIM.AND As amuTED EN IRE wow. 1Fp tel A'i smatir'" �1_I '•'°�?eu`�;;:+`•:�: '' STAeEmn PERGOLA RAs: z Emamrr Hors 9LLO•:• ", � �{,Y_,r;.+l ``...'`k^ u°'/°' ws w nan DTME ma eAu3 NAan ro raw A ••�:•;••'::�:�•••Ja Ar LEAST T..omuT a URAL WARM WAL O EN nwauwi;� ti•• I rAw euE ro Arwm ra w''L• }• I • UsEDEACH w LE Asuns To i2 AHL BALL nORA1 SNOB MONO NAT OE . •s rmE smomD TRAM t " I .AMEN DINT STaDT uw s vuOm TRAP _ EAR R OR tea.AND ART rAw,s m SNAIL ec wmEnm EON . aoDnARar ma�Tm aoawc 9/ALL BE • 0 ALL BARE FARM AREAS sRAu a s Arm wusm As sow As is • ��• sE� PVC RH4 DER �m,� mn9w.A.Eon BAR WIN AREA 9uu DE COM CROP;DUE0.AS SOON AS PR..CAL. RAvm EAOyw SEDGE '! '►� DATFAa SUMMATION. ""'"""c mrmAs wr'a u'sm�iaR TmwwAn, 4�:ii:'x:"aSi23?3k1 s3::ti Ei:' r:-s3i:ir -r_i:: - -- SEMEHT sTS.02N1�RArs°�'9w` CONSTRUCTED caaRo SUM l�s wcw°°R"'a's • I D>uRerE j 'C'�}000•. rTrc °"tee OR MERE Ell AREAS,RE unRm ARE S.M. i¢ue:wD IOU . 'b. l •:"•.: SUMM NETTNO T.NEB SM.AND UNWED 0T AND ARUN�� ON v Tnarrnry ° :!�e:i •-• i .vim La�Den aTo¢s I'mo+"mrNOCRPORA SLME rs�s u • All • Aa:sETNA« -Iu2ww NON semDx �� �. jr6:121-- MOAN wTER'or a•)TrEi mTa sxc IN 9uL a sgnm rTR mm-cwu+rmAsrRmosD aam , a -=1LiyL.wEa r,R�srs`,: mAntixra'Eam.u SWALE wi"T ArsAs 9,uE a_ Aaa.REArA�; �ai J�¢baegg pL== —____-- B.1N CLNRACnp 9wL ow,um mE NER mac . L— uA'iNrc alAamrMOD OF 'ira�mu WATlION ER soar • 0 AS'8MCA O� ° ROCKHLIRST ROAD P�g/0 rf.. �� — G RECEIVED cAq 1 DEC 2120 B k:::IT if WASTEWATER P w n &mowaa octE r j� so.r_Iy -RECORD DRAWING O AnLATa,a MS DmamD En®r sr A uana9 ' - DLMIDr 6 A NLOOR OF IDS EDAWCII I. 1.11 0 _ EN WASTEWATER PLAN premsd(Or MAP REFERENCE Stephen grshan • PROPERTY uNOrER E; BdNp r wftlyuAna 84RDGdaost •AND DEAN LW RATER LOCATION rROy Or0"�ra Mom Car(arb raY �' ACTUAL rOU1m.,ION EaAnar WnD W !£ �[� pC 'OHl°'z0B�e uAa � �Dr NY ]90• zlazowLmrA Y Nmn1Da eNgln,,„„, v.2,...r nor 29131-02-S1 i 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: 19 December 2023 To: LG Legacy LLC (Applicant) Re: System Inspection Site Report for: 84 Rockhurst 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 from 19 December 2023, the date of the inspection. Sincerely, A John O'Brien, Director Budding & Codes Enforcement Town of Queensbury /kd Revised August 2023