2024-0073 Jar
Property Transfer Sewage Disposal Information Form
Town ofQuuccnsbury
742 Bay Road,Queensbury,NY 12804 Date: Z/i 3/Zy
P:518-761-8256 www.queensbury.net
;c k & k Met S a.ti\U0'k
(Name of Applicant)
Re: Onsite Wastewater Treatment System Inspection Information Request for:
(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$275 permit fee). The deposit is forfeited if the
owner fails to complete the repairs or installation as stated above.
If you have any questions, please call.
Phone: (518) 761-8256 Email: kated@queensbury.net
Thank you.
Sincerely,
OA.
John O'Brien, Director
BUJding and Code Enforcement
Town of Queensbury
Property Transfer Packet Revised September 2023
Office Use Only
k.se Permit#:
Town ofQuces cbury Fee:_$ 2?��
742 Bay Road,Queensbury,NY 12804
P:518-761-8206 or 518-761-8205 Invoice#: 'bo( ),
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: „U._ awur16a7 1'(hY r241 tt
Tax map number: 51 3Li06 2 ri ' 7 - Z
Current owner: MtLAtot A Mkt km/ttit(1A.
Mailing Address (c/s/z): 2c0 S e,140y Iu 5 A- k �Cr�.[� �_Y (Z�(j
Cell #: (57i) ? ( -5 S( 2- Land Line#:
Email: IM;14;✓Y14A4-ccw.14i 6 y..Laa• Cd n�
Applicant(if different than above):
Mailing Address (c/s/z):
Cell#: Land Line#:
Email:
❑ Proposed Owner ❑ Realtor ❑ Attorney ❑ Other (explain:
Septic Contractor: Ad-10A St/2 +-rC �G{J c c ,
Mailing Address (c/s/z): 121 Z 564.4:}v}o- 12-1 YIJ Y. 12 "3 (
Cell#: Land Line#: 5 7 — VI NV
Email:
Reason for Inspection Request:
❑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 3 # Bathrooms Z # Kitchens l Jacuzzi tub(s) 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? N'Yes El No
Are system plans available? Yes ❑ No
Does the system(s) serve multiple properties? ❑ Yes Xi No
If yes, describe ):
Maintenance:
Service agreement? ❑ Yes KNo; If yes, business' name
Date of last inspection N/A El 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 t'No
• Sewage-odors? ❑ Yes No
• Direct surface discharge(s)? ❑ Yes Ne No
• Back-up of toilets? • ❑ Yes No
• Back-up of any other fixtures? (e.g. slow drains) ❑ Yes L No
• Seasonal ponding or breakout of leach field? ❑ Yes 0 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):
Please print name:
Signature: 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.
*see Agent Authorization signature page
Property Transfer Packet Revised September 2023
• _moo
OFFICE USE ONLY
TAX MAP NO. PERMIT NO. PERMIT FEE
APPROVALS: ZONING TOWN CLERK
APPLICATION FOR SEPTIC DISPOSAL SYSTEM PERMIT:
A PERMIT MUST BE OBTAINED BEFORE WORK BEGINS.APPLICATION IS SUBJECT TO REVIEW BEFORE ISSUANCE OF A VALID
PERMIT.OWNER:.Arcanc;eto 1\4ct5-Fran-i-oni INSTALLER:
ADDRESS:78 Surre,) i-e,kk Or O ADDRESS:
PHONE NOSS5►a)793 43 O Cv PHONE NOS.
LOCATION OF INSTALLATION: Rea.c-divn R Octd
NO.OF RESIDENCE INFORMATION:
YEAR BUILT BEDROOMS X COMPUTATION= = TOTAL DAILY FLOW
GARBAGE GR`I�QER
1980 or older X 150 gallon per bedroom i INSTALLED? N
1981-1991 X 130 gallon per bedroom = SPA OR HOT TU6
1992-present 3 X 110 gallon per bedroom : 330�/d INSTALLED? O
PARCEL INFORMATION:
✓ TOPOGRAPHY: Flat rolling A/ Steep slope %Slope
✓ SOIL NATURE: Sand ✓ Loam Clay Other
✓ GROUNDWATER: At what depth?7 CA '+�
✓ BEDROCK/IMPERVIOUS MATERIAL: At what depth? > (
✓ DOMESTIC WATER SUPLY: Municipal Well ✓ (If well: Water supply from any septic
system absorption is 7[Cr) ft.)
✓ PERCOLATION TEST: Rate is 3 r71 OS fiec minutes per inch[MPI]
(Test to be completed by a licensed professional engineer or architect.)
PROPOSED SYSTEM FOR NEW CONSTRUCTION: All individual sewage disposal systems must be designed by
a licensed professional engineer or architect(unless installed in a Planning Board approved subdivision).
TANK SIZE: I-0(X) GALLON(MIN. SIZE IS 1,000 GAL.)Add 250 gallons to the size of the septic tank for
each garbage grinder,spa or whirlpool tub.
SYSTEM TYPE:
❑ ABSORPTION FIELD(WITH NO.2 STONE) Total length ft. Each trench X
❑ SEEPAGE PIT(S)(WITH NO. 3 STONE) How many? Size?
❑ALTERNATIVE SYSTEM Bed or other type? 00') E j en Lin A-6
❑ HOLDING TANK SYSTEM Total required capacity?
Tank size? Number of tanks?
1. NOTE: ALARM SYSTEM AND ASSOCIATED ELECTRICAL WORK MUST BE INSPECTED BY A TOWN
APPROVED ELECTRICAL INSPECTION AGENCY. PLEASE REVIEW LIST PROVIDED.
•
For your protection, please note that pursuant to Section 136-29 of the Code of the Town of Queensbury, any
permit or approval granted which is based upon or is granted in reliance upon any material misrepresentation or
failure to make a material fact or circumstance known by or on behalf of an applicant,shall be void.
i
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0es1nSCICA. (--.3
Septic Inspection Report
Office No.(518)761-8256 Date Inspection request received:
Queensbury Building&Code Enforcement Arrive: am/ m Depart am/pm
742 Bay Rd.,Queensbury,NY 12804 Inspector's Initials:
NAME: (Y\Q,S-k-r ni PERMIT NO.: 1 d 'a .3 g
A_LOCATION: ref n,1 INSPECT ON: 9—A(c--/a
RECHECK:
Comments and/or diagram
Soil Type: Sand/Loam/Clay
Type of Water: Municipal/Well Water
Waterline separation distance ft.
Well separation distance ft. •
Other wells: ft.
Well Casing Length 50'+/- Y N N/A
Absorption Field: Total length 44 ft.
Length of each trench €?,'� ft. � �� `'� '
Depth of trenches .
1/4/\
Size of Stone p
ft
�
Seepage Pits: Number
-
Size: x
Stone Size: %Z5\11,\ Z-
Piping Size Type �� PC
Building to tank 4` /�
`
Tank to Distribution Box CV`
Distribution Box to Field/Pit iv- F - z ,
Opening Sealed: _Y .1
End Cap Y,N 1,�{S.ttj ;
Inlet/Outlet Pipes&Baffles IL Y R N am'
Location/SeparationsCO` ( 7
• Foundation to tank _ ft.
Foundation to absorption ft. citt5VIA), ` ` ti Ilfr
Separation of Pits
Confo ms as Ian Y .Y•lemotC21 -
gineer Report and As-Built Y N
Loca o Propergi:: 2 f ,L TO cz -V-5k`
5Fro Rear Left Side •ght SideMiddle Front Middle Rear
System Use Status*
rov _____—_---
Partial Approved and needs to be re-inspected, pl a call the Building&Codes Office
Disapproved
Last revised 06/18/07 L:\Bullding&Codes Forms-OLD\Bullding&Codes\Inspection Fonns\Septic Inspection Reportdoc
Septic Inspection Report
Office No.(518)761-8256 Date Inspection request received:
Queensbury Building&Code Enforcement Arrive: C am/p Depart: t "� " m/pm
742 Bay Rd.,Queensbury, NY 12804 Inspector's Initials: E
NAME: - PERMIT_ NO.: 2-0. C3=Ji
LOCATION: '�-"L. C4.t*`Acn` ..11s't 123) INSPECT ON:
RECHECK:
Comments and/or diagram
Soil Type: Sand/Loam/Clay
Type of Water. Munidpal/Well Water
Waterline separation distance ft. RC.-- —
Well separation distance ft.
Other wells: ft.
Well Casing Length 50'+/- Y N_NIA
[150'to well required if NO]
Absorption Field: Total length ft.
Length of each trench ft.
Depth of trenches ft. "� ;W
Size of Stone 1 N{
Seepage Pits: Number �V
Size: __ x
Stone Size:
Piping Size Type
Building to tank �r - �1 �`� gI
Tank to Distribution Box ,k-
Distribution Box to Field/Pit v- ' D/or L ( -U4
Opening Sealed: NEnd Cap M4.44 Inlet/Outlet Pipes&Baffles N �� riarZ - `! et
Manholes 12"or less below grade Y , `4 6-
[provide extension collar if Yes] Y4:11
5c-d.-.5 -i- I✓F
Location]Separations
Foundation to tank L5 ft.
Foundation to absorption ems-ft.
Separation of Pits A .! C9o `rL4
Conforms as per Plot Plan _
Engineer Report and As-Built Y N RKI2 Q-
ETU Maintenance Contract Y N
provided FiLorikik, Qt (i.4 in)512ARV&c.
Location of System on Property:
Front Rear. Left Side light S Middle Front Middle Rear
System Use Status:
/ Approved
Partial Approved and needs to reins call the Building&Codes Office
Disapproved
L:WPam WhitinA2010\Bu1Iding Codes Foms on Forrrs\Septk Inspection ReporL03 2910.doc
.3 1.
Septic Inspection Report
Office No.(518)761-8256 Date Inspection request received:
Queensbury Building&Code Enforcement Arrive: am/p Depart:.� am/pm
742 Bay Rd.,Queensbury, NY 12804 Inspector's Initials:
�v) -iGK�"�
NAME: irk ")�2c9 j
PERMIT NO.: Z
LOCATION: 42.2. 2) INSPECT ON:
RECHECK:
Comments and/or diagram
Soil Type: Sand/ m lay
Type of Water: Mufiicipal ell Water
Waterline separation distance f.[--.4--ft.
Well separation distance ft.
Other wells: ft.
Well Casing Length 50'+/- Y N N/A
[150'to well required if NO]
Absorption Field: Total length __ ft.
Length of each trench '�l ft.
Depth of trenches ft.
Size of Stone
Seepage Pits: Number VIVO
Size: x
Stone Size:
Piping ize Type Cl" k*--CS MAP
Building to tank
• Tank to Distribution Box I tdZ V ��S
Distribution Box to Field/Pit 1
Opening Sealed: N
End Cap .-.., _____N
Inlet/Outlet Pipes&Baffles V/X N
Manholes 12"or less below grade ✓y�N — yKLI-P[provide extension collar if Yes] Nh�flitii/
vT
Location/Separations 7`� v � "
Foundation to tank -7 '4—ft.
Foundation to absorption c) ft. ,[ >�� �p
�.-- s.�--'�
Separation of Pits M�' 5 ) (� -N ` / +�
Conforms as per Plot Plan _Y N 6 -g �� -- `
Engineer Report and As-Built Y N
ETU Maintenance Contract Y_N
provided
Location em on Property:
•
Fro Rear Left Side Right Side Middle Front Middle Rear
se —
Approved
Partial Approv and needs to be re-Inspected, call the Building&Codes Office
Disapproved
l:\Pam Whiting\2010\&uilding Codes Fomisunspection Forms\Septic Inspection Repo0_03 29 10.doc
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: 14 March 2024
To: Angelo Mastrantoni
(Applicant)
Re: System Inspection Site Report for:
22 Reardon 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 13 March 2024, the date of the inspection.
Sincerely,
A
John O'Brien, Director
Budding & Codes Enforcement
Town of Queensbury
/kd Revised August 2023
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