PT-0706-2023 9 Onc-'11" hal 10-v (Cd11 11'64/ ktir4) (7"--L
Property Transf r Sewage Disposal Information Form
Date: (9 $ /5 &
Town of Queensbury
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net
/ 'itv\(Name of Owner/Applicant)
1
Re: OnsiteW]astewater Treatment System Inspection Information Request for:
4/ / ? -yo,I v 6Y . R(1/,
(Site Address forins inspection)
P )
Thank you for requesting an inspection for the onsite wastewater treatment system (OWTS) located on the
property referenced above. We look forward to completing a thorough inspection for you. You can help us do
the best job possible by providing some advanced information about the site. Prior to our inspection,we request
this completed application, a site map indicating the location of the septic components and confirmation the
pre-inspection preparation (see the last page of this packet) will be completed prior to our arrival.
Enclosed is a Septic System Inspection Information form, which must be completed, signed and returned to
this office, with the appropriate fee(s) and documentation, prior to scheduling an inspection.
Please note the Town of Queensbury's fee for this service is $275. Be advised that all fees must be paid prior to
scheduling the inspection. We require 48 hours notification prior to scheduling the inspection.
If the purchaser is requesting an exemption, please submit this application along with a notarized letter stating
the septic system will be inspected or repaired/replaced within 6 months from the date of the Property
Conveyance or June 15t of the current, or following year (whichever comes first), a map locating the septic
system and payment totaling $2275 ($2000 refundable deposit plus $275 permit fee). The deposit is forfeited
if the owner fails to complete the repairs or installation as stated above.
If you have any questions, please call.
Phone: (518) 761-8256 Email: kated@queensbury.net
Thank you.
Sincerely, �� �'.�'' ��.� �tp.r If,:,
Ol/litv\)116
roe;,
Nofc
John O'Brien, Director P
BuJding and Code Enforcement
Town of Queensbury
Property Transfer Packet Revised July 2022
-` Office Use Only
Permit#: fi =�Cb - Zfl
To.of Q ccnsbury Fee:_$ LF9�
742 Bay Road,Queensbury,NY 12804 ����
P:518-761-8206 or 518-761-8205 Invoice#:
www.queensbury.net
SEWAGE DISPOSAL SYSTEM INSPECTION INFORMATION (�- °�0 °Z )
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)
IC
Property address for inspection: `J" FrGlitA ((
Tax map number: vW 1 ---
Property owner: '/' / 0+&01
Mailing Address (c/s/z): e . ,AV Pt V '`W
Cell #: -5 1g-,,53 ` WO-
Land Li #: ,:1/V '--1u6rs-9
Email: �i , in/ /2,7 71�04�' Ca/
Applicant (if different than above):
Mailing Address (c/s/z):
Cell #: Land Line#:
Email:
❑ Proposed Owner ❑ Realtor ❑ Attorney ❑ Other (explain: )
Iiitt Z2I2T- ,_ ifgAZ' / --
Septic Contractor: �C
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 3 # Bathrooms # Kitchens &Jacuzzi tub(s)')g), Garbage grinder
Onsite Wastewater Treatment System:
How many systems are on the property? ' 3
Year system(s) installed: T no �6J1 '
ank �� Size of Septic Tank �J
Type of Absorption System: SQ 44 ' M'‘,-Ik
Are all system components wholly within the property boundaries? ❑Yes 0 No
Are system plans available? Yes El 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 \ 1, N/A ❑
Frequency of pumping N/A ❑
List known repairs/replacements, with dates:
Date Type of Repair/Replacement
Operation:
System problems? El Yes le No
Sewage odors? IIIYes r No
. Direct surface discharge(s)? ❑ Yes k No
. Back-up of toilets?. ❑ Yes [2 No
. Back-up of any other fixtures? (e.g. slow drains) ❑ Yes No
. Seasonal ponding or breakout of leach field? ❑ Yes V No -
Property Transfer Packet Revised July 2022
Statement of Acceptance of Conditions:
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 pr perty owner or authorized agent:
Affiliation: owner ❑agent ❑ other:
Please print name: Ctrq7
Signature: M Date: d i5#5
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
Craig F. Brown
27 Antigua Road
Lake George, NY 12845
518-668-2556
Cbhammer27@gmail.com
December 8,2023
•
Town of Queensbury
742 Bay Road
Queensbury, NY 12804
ATTN: John O'Brian
As discussed,we will not be able to conduct the septic testing till spring 2024 because my
backhoe was not available and my foreman has been out of work due to health issues . We will
get this done in mid April to mid May.
Sincerely, Craig Brown
4frd
®EC 0 8 2023
TOV1lf�t OF QU CNSBURY
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TABITHA L.SCHADWILL
NOTARY PUBLIC STATE OF NEWYORK
WARREN COUNTY
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- 239.17-1-8 PT-0706-2023
•. . . Antigua Resort LLC isitE1-7-4C 1 / —714 L,
27 Antigua Rd, 2-unit
,
•
• • Property Transfer -- deed transfer
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: 2 May 2024
To: Craig Brown
(Applicant)
Re: System Inspection Site Report for:
27 Antigua Road, 2-unit addition,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 froml May 2024, the date of the inspection.
Sincerely,
A
John O'Brien, Director
Budding & Codes Enforcement
Town of Queensbury
/kd Revised August 2023