PT-0719-2023 Property Transfer Sewage Disposal Information Form
Town orQuecnstniry �f 22
742 Bay Road,Queensbury,NY 12804 Date: I\ 7'O 2'
P:518-761-8256 www.queensburv.net l
M' aw -k (ffi
(Name of Applicant)
Re: Onsite Wastewater Treatment System Inspection Information Request for:
C hr L uo o1 U
(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 15t of the current, or following year (whichever
comes first)
• the map locating the septic system
• payment totaling$2275($2000 refundable deposit plus$275 permit fee). The deposit is forfeited if the
owner fails to complete the repairs or installation as stated above.
If you have any questions, please call.
Phone: (518) 761-8256 Email: kated@queensbury.net
Thank you.
Sincerely,
John O'Brien, Director
Building and Code Enforcement
Town of Queensbury
Property Transfer Packet Revised September 2023
Office Use Only
` Permit#: 0c,- 2Zo le)
Th�,,n ofTtlecerisbury Fee:_$ 2.2Th
742 Bay Road,Queensbury,NY 12804
P:518-761-8206 or 518-761-8205 Invoice#: n"
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: I ( €'I t2.b /tL, b Ueix6bur vU( Q�
j�y� ,
Tax map number: 52,5 11 0° )-81 A I- f 0
Current owner: AU,.Q21J 1/
Mailing Address (c/s/z): j (3 $/tow K) qU )5 JJ ' ISO
Cell#: 9,' W1 I4 Land Line#: p/f
Email: 1/a/O hOrt/14 ehp CI Wit e 0/
TECEOVET'i
Applicant (if different than above):
Mailing Address (c/s/z): NOV 0 7 2023 Iii
Cell #: Land Line#:
TOWN Or OUEENSBURY
Email: BUILDING&CODES
❑ Proposed Owner ❑ Realtor ❑ Attorney ❑ Other (explain: )
Septic Contractor: AlJI ,U ct( �r9{rW` a
Mailing Address (c/s/z): ?0 17/24 &1124'5 Falb a8Of
Cell#: 5W' IV, - J1(OQ Land Line#:
Email: &d re(I osar et m(,L(
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 "I # Bathrooms.4 # Kitchens I Jacuzzi tub(s) U' Garbage grinder
"I I g
Onsite Wastewater Treatment System:
t
How many systems are on the property?
1
Year system(s) installed: Tanklo9 Size of Septic Tant a() Type of Absorption System:
Are all system components wholly within the property boundaries?/t Yes ❑ No
Are system plans available? ❑ Yes No
Does the system(s) serve multiple properties? ❑ Yes >] No
If yes, describe ):
Maintenance:
Service agreement? ❑ Yes 6No; If yes, business' name
Date of last inspection N/A ❑ Date tank last pumped I Ff(I/ N/A ❑
Frequency of pumping _ N/A ❑
List known repairs/replacements, with dates:
Date Type of Repair/Replacement
Operation:
System problems? ❑ Yes kj No
• Sewage odors? ❑ Yes 'No
• Direct surface discharge(s)? ❑ Yes 'No
• Back-up of toilets? ❑ Yes No
• Back-up of any other fixtures? (e.g. slow drains) ❑ Yes h' No
• Seasonal ponding or breakout of leach field? ❑ Yes No
Property Transfer Packet Revised September 2023
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 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: i a/ V 0 /
Signature: 114a/aebtOttaf Date: Afail AeZ-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.
see Agent Authorization signature page
Property Transfer Packet Revised September 2023
EXEMPTION CONDITION OPTIONS
PLEASE CHOOSE ONLY ONE CONDITION BELOW IF YOU ARE REQUESTING A WAIVER
Due to one of the conditions listed below, I am requesting an exemption from the
Septic Inspection Upon Property Transfer by the Town of Queensbury:
❑ The property to be sold or transferred will not be inhabited, and the new owner plans to demolish the
existing structure. In order to qualify for the exemption, a notarized affidavit must be submitted to the
Building and Codes Enforcement Office stating that the dwelling will not be inhabited and that it will be
demolished with no immediate plans to rebuild or the dwelling will not be inhabited, it will be
demolished and rebuilt, in which case the affidavit shall be accompanied by a site plan, including
adequate detail to demonstrate a lawful OWTS, together with a check payable to the Town of
Queensbury in the amount of$2,000. Such funds will be held in a non-interest-bearing escrow account
and will be released,in the former case, upon issuance of a demolition permit and, in the latter case,
upon issuance of a certificate of compliance from the Building and Codes Enforcement Office.
If the Property Transfer inspection is not completed within that 6 (six) month
timeframe, the $2000 will be forfeited.
An OWTS inspection was not able to be completed prior to the conveyance of real property due to
inclement weather. In order to qualify for the exemption, a notarized affidavit from the new property
owner to complete the requisite OWTS inspection within six months of the date of the conveyance of
real property, or June 1,whichever comes first, must be filed with the Building and Codes Enforcement
Office. A check payable to the Town of Queensbury in the amount of$2,000 will be held in a non-
interest-bearing escrow account and shall be released upon the completion of a satisfactory OWTS
inspection from the Building and Codes Enforcement Office.
If the Property Transfer inspection is not completed within that 6 (six) month or
June lst timeframe, the $2000 will be forfeited.
❑ The property to be sold or transferred contains an existing OWTS that does not comply with the
provisions of this article, and the prospective purchasers and/or the Seller wish(es)to forgo an
inspection in favor of installing an approved OWTS within six months of the transfer of property. In
order to qualify for the exemption, a notarized affidavit must be submitted to the Building and Codes
Enforcement Office stating that the existing OWTS will be replaced within six months from transfer of
property. The affidavit must be accompanied by a site plan, including adequate detail to demonstrate
that the replacement OWTS will comply with this article,together with a check payable to the Town of
Queensbury in the amount of$2,000. Such funds will be held in a non-interest-bearing escrow account
and will be released upon issuance of a certificate of compliance from the Building and Codes
Enforcement Office.
If the Property Transfer inspection is not completed within that 6 (six) month
timeframe, the $2000 will be forfeited.
Property Transfer Packet Revised September 2023
❑ 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
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
six months from the date of the conveyance of real property, or June 1, whichever comes first,must be
filed with the Building and Codes Enforcement Office. A check payable to the Town of Queensbury in
the amount of$2,000 will be held in a non-interest-bearing escrow account and shall be released upon
the completion 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 within that 6 (six) month or
June 1st timeframe, the $2000 will be forfeited.
❑ There is a record of an approved septic system inspection upon property transfer permit and
inspection completed and passed within the last five (5) years. Please provide a copy of this record.
PLEASE READ NOTICE THOROUGHLY:
Failure to complete the inspection, obtain the 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 Codes Enforcement Office will result in forfeiture of the
moneys held in escrow, and the Town may use such funds toward abating the conditions caused
by each such violation of this article.
Inspections must take place within one (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.
***ONLY SIGN THIS PAGE IF YOU ARE OPTING FOR A WAIVER REOUEST!!***
I have read and understand the above notice regarding the expectations and possible forfeiture
of moneys submitted to the Town of Queensbury for an exemption request.
Affiliation: ❑ seller ❑seller's agent* El other (specify):
/iiI,, i11
Print Name: 1 ( {- 4
Sign Name: ) 00-1// Date: �i3
Affiliation: ❑ buyer ❑ buyer's agent* ❑ other (specify):
Print Name:
Sign Name: Date:
*see Agent Authorization signature page
Property Transfer Packet Revised September 2023
1
MAUREEN A. VALENTI
113 BIRDSALL ROAD c \\,f7
QUEENSBURY, NY 12804 p711
201.679.3026 NOW 0 8 �
TOWN C)°-4(Ali rODES
BULDI
I, Maureen A. Valenti, residing at the above address, do promise to have a septic
inspection performed by the Town Of Queensbury on or before June 1, 2024 at
such property. Due to potential inclement weather, I am requesting a waiver to
extend the date of the inspection beyond the 6-month time limit.
himik)o-d4474-J tM2 3
Maureen A. Valenti Date
(Applicant)
Cam, , c I ' 17-0
Notary Public Date
State of NQA,v 106 DIANE M. FOSTER
Witiri Public, State of New York
eArt toga Co.#01 F06320974 nri
66mi iinalon Expires March 9,20 O
County of \\(A i0,1
Typed or Printed Name . G.Anl? fV\
My Commission Expires 31q ��
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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: 8 May 2024
To: Maureen Valenti
(Applicant)
Re: System Inspection Site Report for:
113 Birdsall Road, 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 7 May 2024, the date of the inspection.
Sincerely,
A
John O'Brien, Director
Budding & Codes Enforcement
Town of Queensbury
/kd Revised August 2023