PT-0410-2021 Property Transfer Sewage Disposal Information Form
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Date: (1,11/al
Town of Queensbury
742 Bay Road,Queensbury,NY 12804 •
P:518-761-8256 www.queensbury.net
OIDAb
(Name of Owner/Applicant)
Re: Onsite Wastewater Treatment System Inspection Information Request for:
(o(o 'outtuirs+ czo
(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 15t of the current, or following year (whichever comes first), acmap locating the septic
system and payment totaling$2275 ($2000 refundable deposit plus$275 permit fee). The deposit is forfeited
if the owner fails to complete the repairs or installation as stated above.
If you have any questions, please call.
Phone: (518) 761-8256 Email: kated@queensbury.net
Thank you.
•
Sincerely,
_ , , _ , i A' „' ,';
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David Hatin, Director; rjjuNBuilding and Code Enforcement
Town of Queensbury
Property Transfer Packet Revised April 2021
Office Use Only
Permit#: e4\'Q 2Q21
Town o&Clew „; Fee:_$ 2-2 3c J
742 Bay Road,Queensbury,NY 12804
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: (p(p Q oC iOtu rst Rd
Tax map number: �122� •1-5 ' 2 "
Property owner: Glom Mailing Address (c/s/z): la 1 eri 44041 W V 0Y, o N 01 q el
Cell #:q73 '7ipq• 31d Line#:
&1
Email: cutia V� . ref CF 0 V
p [ CE
Applicant (if different than above): JUN 0 1 2021 I
Mailing Address (c/s/z): ` TOWN OF QUEENSBURY
Cell#: Land Line#: BUILDING& CODES
Email:
❑ Proposed Owner ❑ Realtor LI Attorney ❑ 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 April 2021
HOUSEHOLD INFORMATION
**PLEASE SEE SEPARATE PAGE FOR EXEMPTIONS**
1
# Bedrooms A # Bathrooms 2 # Kitchens t Jacuzzi tub(s) Pik Garbage grinder . "
Onsite Wastewater Treatment System:
How many systems are on the property?
Year system(s) installed: Tank Size of Septic Tank
Type of Absorption System:
Are all system components wholly within the property boundaries? IkKes ❑ No
Are system plans available? ❑ Yes VW)
Does the system(s) serve multiple properties? ❑ Yes io
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:
Date Type of Repair/Replacement
Operation:
System problems? ❑Yes peNo
• Sewage odors? ❑ Yes Q' No
• Direct surface discharge(s)? ❑ Yes Ikrrlo
• Back-up of toilets? ❑Yes
• Back-up of any other fixtures? (e.g. slow drains) ❑Yes ✓Q�N
• Seasonal ponding or breakout of leach field? ❑ Yes Ro
Property Transfer Packet Revised April 2021
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 20% of the fee is retained by the Town of
Queensbury.
Signature of property owner or authorized agent:
Affiliation: owner ❑agent ❑other:
Please print name: Q GIOWO
Signature: Date:
(9r1/zI
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 April 2021
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.EXEMPTION..:CONDITION.!OPTIONS
Dueto..one of the.conditions.listed.bolo:W.,I am requesting an.exemptiOn.frOm the.
.Septie:InSpeetiotrpPon'Property:Transfer by..the Town:Of QueensbUryf.
la The property to be Sold or transferred will not be ioobite4,.and.tho new after plans to deintilish.the
existing structure Tn.orderto qualify-for the e?certiption,a notarized affidavitinust be submitted to
Building and Codes Enforcement Office stating that the dwelling not be inhabited.and.lb4 it will be
demolished with no immediate plans to rebuild or the dwelling will not be iribabited,it will be
demolished and rebuilt, in .case the affidavit shall be accompanied by.a..site.plan,.including
adequate detail to demonstrate.a lawful OWTS,together with.a..thea.payabld,to the Town of
Queettsbuty.intheamourit of$2;000. Such funds will be held in a non4nterestbeating escrow account
• and will be.released,in the former case,upon issuance of a demolition permit in the latter case,
ppori:isSuariCeof.t certificate of compliance from the Building and Codes Enforcement Ciffice. If.the
Property Tea-WO inspection is not completed within that 6.(Six) month timeframe,.
*bo$2.909 will The.forfeited.
O .An-OWTS.inspection was not abletdbocoMpletedprior to the conveyance of real property due to
inclement wotller...4(otdd.r10.qualify for the exemption,a notarized affidavit from the new property
owner to.complete therequisite.10.WTS.inspection within six months of the date of the conveyance of
:real property,:Or.,Tune.1,whichelier cthilbg.first,must be filed with:the Building and Codes Enforcement
Office,A checkpayable to the Town of•Quesensbury in theumount.,of$2,000 will be held in anon,
interest-bearing eSerelkdocountandishall be released upon the completion of a satisfactory OWTS
inspection from the):404ing:04.0000. ; ilt*onion'Officejf the Property Transfer
inspeCtion is not completed within that 6(six)month or-illine,18t thneframe, the
.$2000.will beforfeited.
Thepropertyto.be:sold Or transferred contains an.ekistingOWTS..that.does not.comply with the
Cyti provisions of this article, and the prospective purchasers:and/Or the Seller wish:lb:forgo an inspection.
:in favor of installing an apprOed.OWTS:within SiltiolithS::Of the trAtidet of property.In order to.
XR..7-- qualify for the exemption, notarized affidavit must be submitted to the Building 4,14.Q0dOs.
Enforcement Office stating thatthe existing OWTS.will be replaced within-s4;months.froin transfer of
:property. The affidavit must.beiaecompoiedby,a.site plan,including adequate detail to demonstrate
that the.replacement:OWTS will..domply with this attiCie,:together,with.g.ejlepkpoya:ble to the Town of
Qpeerisliory!imthe amount of$2,000 Such funds will be held in asnon-intereStbearing...escrow.account
and will be released upon issuance of ac..ertificate of compliance feOpirtboRoilding and.Codes. .
Enforcement Office If the Property Transfer inspection is not completed within that 6. .
(Six) month.fitneframe,the $2000'will be:fOrfeited..
• •
..PropqtyTriiiiger Pkija0t 2019
, .
0 :Duringthe OWTS inspection,a„White:Of theieptic system was determilned.Due O winter and
frozen:conditions,the repair to an existing:OWTS,couitlitofocenr or a tiew:OWTS:coold not be
installed before the conveyance of real property.In circlet fO.-.cinalify for the exen-iption„anotatithqd
.affidavit from the:neW.preperty.ones to.complete ;installation orrepair of the septic.SyStern.WithM
. - - , - .; •• -••
six months'frOMtlierdate of the conveyance bf real property; or June 1,..whichever comes:first,.must be
filed with the:Bitilding;and;code -4torcei.m.ettt Office.Xeheek payable to the Town of Queensbnry in
the amount PAC(will be.heldin a non-interest-bearing escrow account and shall he felcocct-npon
.the completion of the repair or installation of anew septic system anda:satisfaCtory OWTS inspection
front the Building and:iCedeS.Enforeetheht Offite,.if the.Property Transfer inspection is not
completed within:that 6,.(six)month oe4wivilstfinaerrame,thex-$2000-will be.
forfeited-.
, .
:C=1. Pieie.is a record:94 septic,:system inspection upon property transfer permit:.arid.inspection completed
and passed yvithin the laStthree•years.. Please-provide a...cc.loy-of this record.
PLEASE READ.NOTICE THOROUGHLY::
Failure to complete the inspotion,:ohminthepermit or complete all repairs/installations.i
identified in thepreceding:sabsectiong-of this section within the time provided or any subsequent
deadline established bytheJpagding.-anct.codes Enforcement Office wiliresult in forfeiture of the
moneys 404.in!escrow,.and-the;Town na#3,i'visp.such funds toward abating:the conditions caused
by each such violation*thisorticle, .
Inspections must plaCe:Wit4irtone(I) year of submission.of a completed application,.
Inspections scheduled to take place after the one year.period will be..sUbjectta.Stibini$000
of'arenewatapplicationandliqment of the renewal based on the:current'fee.-schedUle.:
I have read and understand the Above notice regarding the expectations and possible.forfeiture
Of.rnOrtey .gnbthitted to•the Townof.940e0bury for an exemption request.--
•Seller:
Print Name: . . • :=.. .43 . ...:i.'...:6-cithutival. . . C.: . .... .
A6- - •••••. '2. - - ..- - - .: CU- :Date:: .. . .. ..:
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sl 09/30/2020
Sign Ngmet... . ,.)y..:Rod*-.-6 LLC (4-_, 064 PM GMT:. Date:
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B.uyer:..
Print:Name: .C.ICAdif- -Gl•:('6 oilb Date:...... . . .:.:
..... ..... ... ... . .... ..
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Sign Name ..a./1/..# - •. artlik 10
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5.1 0501 PM GMT
Date::
PitiptrtylidOsftPackgt , Ittvittd:Octilier2019
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MARIA A: GAGLIARDI
Notary Public, State of New York
No.01 GA6061460
Qualified in Warren County ?
Commission Expires July 16, o2o Z
❑ During the OWTS inspection, a failure of the septic system was determined. Due to winter and
frozen conditions,the repair to an existing OWTS could not occur or a new OWTS could not be
N\ installed before the conveyance of real property. In order to qualify for the exemption, a notarized
affidavit from the new property owner to complete the installation or repair of the septic system within
i c\months from the date of the conveyance of real property, or June r whichever comes first, must be
filed\with the Building and Codes Enforcement Office.A check payple to the Town of Queensbury in
the amount of$2,000 will be held in a non-interest-bearing escrow14ccount and shall be released upon
the complet'ioon of the repair or installation of a new septic system/and a satisfactory OWTS inspection
from the Building and Codes Enforcement Office. If the Property Transfer inspection is not
completed wk in that 6 (six) month or June lst timeframe, the $2000 will be
forfeited. /Jr
❑ There is a record of a septic ystem inspection upon property transfer permit and inspection completed
and passed within the last three years. Please provide;'a copy of this record.
\ /
PLEASE READ NOTICE THOROU,GHLYV/
Failure to complete the inspection, obtaiithe permit or complete all repairs/installations
identified in the preceding subsections of this/section within the time provided or any subsequent
deadline established by the Building and Cp�des Enforcement Office will result in forfeiture of the
moneys held in escrow, and the Town may/use su h funds toward abating the conditions caused
by each such violation of this article. /
,;' \\ . .
Inspections must take place withiuyone (1) year of submission of a completed application.
Inspections scheduled to take place after the one year,period will be subject to submission
of a renewal application and payment of the renewal fee based on the current fee schedule.
r \
***ONLY SIGN THISP.dGE IF YOU ARE OPTING FOR WAIVER REQUEST!!***
I have read and understan,d`the above notice regarding the expectations and possible forfeiture
of moneys submitted to he Town of Queensbury for an exemption request.Selle
K
3 R oc hus+ \
Print \
Print Name: ,
Sign Name: Date:
.
Buyer:
Print Name,:
Sign Na e: Date:
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Property Transfer Packet Revised April 2021
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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: 28 December 2023
To: Kim & Gary Glomb
(Applicant)
Re: System Inspection Site Report for:
66 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 28 December 2023, the date of the
inspection.
Sincerely,
A
John O'Brien, Director
Budding & Codes Enforcement
Town of Queensbury
/kd Revised August 2023