2024-0406 , w Property Transfer Sewage Disposal Information Form
Town of Queensbury
742 Bay Road,Queensbury,NY 12804 Date: gA 2 f
P:518-761-8256 www.queensbury.net
5co1 Al s lei
(Name of Applicant)
Re: Onsite Wastewater Treatment System Inspection Information Request for:
L 4i1lM.add .(1oi, Q e.eAsLU�'
(Site Address for Inspection) U
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$275 permit fee). The deposit is forfeited if the
owner fails to complete the repairs or installation as stated above.
If you have any questions, please call.
Phone: (518) 761-8256 Email: kated@queensbury.net
Thank you.
Sincerely,
John O'Brien, Director
Bujding and Code Enforcement
Town of Queensbury
Property Transfer Packet Revised September 2023
Office Use Only
r;,s Permit#: 202- 1('0 v6)
•
Towne(1,mc l;1!y Permit Fee: 7 S-,0
742 Bay Road,Queensbury,Nl2
4eP� (� Invoice#
P:518-761-8206 or 518-761-820 �i !�
www.queensburv.net
AUG O 6 2024 � Flood Zone? Y TYPE: • N
TOWN OF OUEENSBURY
BUILDING&CODES
SEWAGE DISPOSAL-SYSTEM-IN IN 'ECTION INFORMATION
Individual Residential Wastewater Treatment System
CONTACT INFORMATION (please print legibly or type and include an email address)
Property and Owner Information: (Please attach property survey or tax parcel map)
Property address for inspection: 1k \t 1 Mct.& ,0o, Q v teal\S Ip u 5 y
Tax map number: 5 Z3 1-1"0 ZZ`7 e l 7 I --9, 3
Current owner: SC01- 411
Mailing Address (c/s/z): 1-F it; &0a J u� p �� I ?PO`f
Cell #: 5I8 -36f ^- IZg7 I Land Line#:
Email: SGO ®t(�v.! (' a 661-1 p`trn7C-16L®LOcM
Applicant (if different than above):
Mailing Address (c/s/z):
Cell #: Land Line#:
Email:
Proposed Owner _Realtor Attorney Other (explain:
Septic Contractor: I D$ 6e ,4i t - ° - 1Lc yestl rcc
Mailing Address (c/s/z): 2 Lower t-e4A '4cee.+
Cell #: 5(6 -3 ,J- O i ' 5 Land Line#: 5 18- 7 9 8--
Email:
Reason for Inspection Request:/
On the market ✓Future listing Sale Pending Deed Transfer _Other:
Property Transfer Packet Revised May 2024
HOUSEHOLD INFORMATION
**PLEASE SEE SEPARATE PAGE FOR EXEMPTIONS**
# Bedrooms 3 # Bathrooms 3I/7- # Kitchens \ Jacuzzi tub(s) t Garbage grinder O
Onsite Wastewater Treatment System:
How many systems are on the property? \\o‘,``
1 ova a�(��
20®7 `1y5 �.al
Year system(s) installed: Tank Size of Septic Tank Type of Absorption System'C: 5�-e�cSo =( L ze5a
Are all system components wholly withinthe property boundaries? NO ✓YES
Are system plans available? _NO YES
Does the system(s) serve multiple properties? vO YES
If yes, describe ):
Maintenance:
Service agreement? f NO YES; If yes, business' name
Date of last inspection N/A Date tank last pumped S/ z-z- N/A
Frequency of pumping 2-'3 U•e8-6 N/A
List known repairs/replacements, with dates:
Date Type of Repair/Replacement
Operation:
System problems? _Yes '{No
• Sewage odors? _Yes VNo
Direct surface discharge(s)? _Yes "No
• Back-up of toilets? Yes o
• Back-up of any other fixtures? (e.g. slow drains) _Yes No
• Seasonal ponding or breakout of leach field? _Yes vo
Property Transfer Packet Revised May 2024
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: 6Lo
Signature: ,j Date: g ,721-
l
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 May 2024
PROPERTY TRANSFER SEWAGE DISPOSAL INSPECTION LETTER
Satisfactory Compliance Notice
Town of Qyccnsbury
Building&Codes Enforcement
742 Bay Road,Queensbury, NY 12804-5902
P: 518-761-8256 www.gueensbury.net
Date: 16 August 2024
To: Scott Kingsley
(Applicant)
Re: System Inspection Site Report for:
4 Hillman 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 from14 August 2024, the date of the inspection.
Sincerely,
A
John O'Brien, Director
Budding & Codes Enforcement
Town of Queensbury
/kd Revised August 2023