2024-0411 Office Use Only
Permit#: ao 4 OW/
TO1171 ofccurcnsbory. Permit Fee: .a 7S.op,
742 Bay Road,Queensbury,NY 12804
P:518-761-8206 or 518-761-8205 AUG 0 7 2024 Invoice#:kkii
www.queensbury.netFlood Zon ? Y TYPE: • N
TOWN OF OUEENSBURY
BUILDING& CODES
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: 9 Glen Hall Drive , Queensbury, NY 12804
Tax map number: 289.11-1-33
Current owner: Ronald B. Mackowiak
Mailing Address(c/s/z):
same as inspection address ¢
Cell#: 203-969-5726 Land Line#: none
Email: rmackow77@gmail.com
Applicant(if different than above):
Mailing Address(c/s/z):
Cell#: Land Line#:
Email:
❑Proposed Owner ❑Realtor ❑Attorney ❑Other(explain: )
Septic Contractor:IBS Septic
Mailing Address(c/s/z): 2 Lower Warren St , Queensbury, NY 12804
Cell#: Land Line#: 518-798-8194
Email:
Reason for Inspection Request:
❑On the market OFuture listing Dale Pending 1 Deed Transfer nOther:
Property Transfer Packet Revised May 2024
HOUSEHOLD INFORMATION
**PLEASE SEE SEPARATE PAGE FOR EXEMPTIONS**
# Bedrooms E # Bathrooms❑3 # Kitchens Q Jacuzzi tub(s)0 Garbage grinder yi
Onsite Wastewater Treatment System:
How many systems are on the property?" 14✓ ��
/az, 751444 F-v3:o tea, -
Year system(s) installed: TankeAfSize of Septic Tank_Type of Absorption System:
Are all system components wholly within the property boundaries? NO AYES
Are system plans available? ❑NO ErES Z9'7z Z—O z-•r$� , z3
Does the system(s) serve multiple properties? Q NO ❑YES �'C 74 2- -a/"6-/ y �fjy
If yes, describe ):
Maintenance:
Service agreement? NO ❑YES; If yes, business' name
Date of last inspection f//2/ /N/A❑ Date tank last pumped I/ N/A❑
Frequency of pumping ;7 Y)/ri N/A❑ t/YLV 79"14/1ir-
List known repairs/replacements, with dates:
Date Type of Repair/Replacement
Operation:
System problems? es No
Sewage odors? es No
• Direct surface discharge(s)? es No
• Back-up of toilets? es No
• Back-up of any other fixtures? (e.g. slow drains) es N
• Seasonal ponding or breakout of leach field? es o
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: Ronald B. Mackowiak
Signature: Date:8/7/24
Prior to scheduling with the Town of Queensbury,you MUST: � � ��� /i', in'
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: 28 August 2024
To: Cynthia and Ronald Mackowiak
(Applicant)
Re: System Inspection Site Report for:
9 Glen Hall Drive, 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 from28 August 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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