2024-0472 •_ . a - ' .ge_Disposal Information Form
t
lECEOWEn
Town ofQuee sn 6 ry SEP 0 3 2024 Sy��. 3 DI 7
742 Bay Road,Queensbury,NY 12804 ate: l/
P:518-761-8256 www.queensbury.net
TOWN OF QUEENSBURY
/ BUILDING&CODES
//erLtr* �q..SSQ,
(Name of Applicant)
Re: Onsite Wastewater Treatment System Inspection Information Request for:
6. '1_ f Trearc�vn g J. Q.,R"�st.,
7
(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$275 permit fee). The deposit is forfeited if the
owner fails to complete the repairs or installation as stated above.
If you have any questions, please call.
Phone: (518) 761-8256 Email: kated@queensbury.net
Thank you.
Sincerely,
VOt ,
John O'Brien, Director
Btj'ding and Code Enforcement
Town of Queensbury
Property Transfer Packet Revised September 2023
Office Use Only
IIECEEIVIE ":;\ Permit it 0.9 --0 a'
To„i,ofCLuccn;bury Permit Fee:$ 1�17°
742 Bay Road,Queensbury,NY 12804 _ SEP 0 3 2024
Invoice U:
P:518-761-8206 or 518-761-8205
www:queensbury.net TOWN OF QUEENSBURY
BUILDING&CODES Flood Zone? Y TYPE: ; N
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: C1 6Arcit,p d
Tax map number:Current owner: (A)c, Se/s i G ✓ / r5I r4 /-ero,i / O cossy)
Mailing Address (c s z): (1 c.c
Cell #: 71 y. 3 7) VT Land Line #:
Email: t-3c 5SP feN"-•, 1 ( o o/ , Cpr-%
l
Applicant (if different than above):
Mailing Address (c/s/z):
Cell #: Land Line#:
Email:
Proposed Owner Realtor _Attorney _Other (explain:
Septic Contractor: Pb r) S-C1 n:44 r✓ Je114 r
Mailing Address (c/s/z):
Cell #: 51? 7 ( 37 ' 0 Land Line#: SA' 7 9 2 7 S7
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 a # Bathrooms IA # Kitchens / Jacuzzi tub(s) 0 Garbage grinder b
Onsite Wastewater Treatment System:. '
How many systems are on the property? / A1Sor b.,
�Isbv A
Year system(s) installed: Tank 7�)1Size of Septic Tank/0b`�Type of Absorption System: a!
Are all system components wholly within the property boundaries? _NO YES
Are system plans available? _NO (YES
Does the system(s) serve multiple properties? -k NO YES
If yes, describe ):
Maintenance:
Service agreement? 1 NO YES; If yes, business' name �r.7 Jewe r
Date of last inspectioV N/A_ Date tank last pumped 9 23 N/A
Frequency of pumping /-2 yr. N/A
List known repairs/replacements, with dates:
Date Type of Repair/Replacement
Operation:
System problems? _Yes ✓No
• Sewage odors? Yes a/No
• Direct surface discharge(s)? Yes vNo
• Back-up of toilets? _Yes a/No
• Back-up of any other fixtures? (e.g. slow drains) _Yes ✓No
• Seasonal ponding or breakout of leach field? _Yes Flo
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: J]Crer-* t 5 $`e
Signature: 24/",Y/ /L Date: p1• .3 o.zy
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
N
INSPECTION WORKSHEET (SEP-0034:10 201`9)
Town of Queensbury-Building and Codes-Fire Marshal
742 Bay Road -(518)761-8256 Building (518)761-8206 Fire Marshal
Case Number: SEP-0322-2019 Case Module: Permit
Inspection Date:Fri Jun 7, 2019 Inspection Status: Failed
Inspector: John O'Brien Inspection Type: Septic
Job Address: 62 REARDON RD Parcel Number: 289.7-1-14
Queensbury, NY 12804
Contact Type Company Name Name
Contractor Hilltop Construction
Primary Owner Wassey Family, Inc.
Engineer Hutchins Engineering
Granted Permission Wassey Family, Inc.
Applicant Wassey, Herbert
Checklist Item Passed Comments
Building Inspector Notes NO 6/7/19 Septic System Not Approved
Remaining Items:
-Final Electrical inspection
-Tom Hutchins Final Report
6/7/19 Septic System Failed
-Received Engineer's As-Built and Final Report
Remaining Item:
- Final Electrical Inspection
Type of Water: Municipal/Well Water YES Well
Well separation distance YES All neighboring and own wells are more than 100'from
absorption bed. EDll '
) EEC
SEP 0 3 2024
TOWN OF QUEENSBURY
BUILDING&CODES
Jun 07,2019 Page(1)
-,r •,){ SRECTION WORKSHEET(SER D03410 2019) • :.`
Checklist Item Passed Comments
Absorbtion Fields:Total Length YES 70'
15'x25'Absorption Bed
Length of Each Trench YES 3 @ 20'
Depth of Trenches YES 24"-36"
Stone Size: YES #2
Building to Tank YES 4"sch40 pvc From House To Pumpstation
2"Plastic Forcemain To 4"sch40 pvc at top of hill From
Pumpstation to Septic Tank.
Tank to Distribution Box YES 4"sdr35 pvc
Distribution box to Field/Pit YES 4"sdr35 pvc to 4"sdr35 pvc perforated with end looped
End Cap YES End looped
Foundation to Tank YES 11'
Foundation to Absorption YES 21'
Engineer Report and As-Built YES 6/7/19 Septic System Not Approved
Remaining Items:
- Final Electrical Inspection
-Tom Hutchins Final Report
1
Jun 07,2019 Page(2)
3 SPECTI N WORKSHEET (S P-003410 2019) F
Checklist Item Passed Comments
System Use Status NO 617/19 Septic System Not Approved
Remaining Items:
-Final Electrical Inspection
-Tom Hutchins Final Report
6/7/19 Septic System Failed
- Received Engineer's As-Built and Final Report
Remaining Item:
-Final Electrical Inspection
nen, o n nspector
Jun 07,2019 Page(3)
•
:- " b „ 'S NSPECTION WO'RKSkIEET(SEP.�003379 2019) •k
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�.. .�",,:"�. . ._.. „>...��' +.x-_.. . , o_iF•. ...i. s..•.. .s. ,� i' . . ,ex.r ,,v. .,_ ,_ ._�d`. , can• .. . .'�..� ,^' ,._..
Town of Queensbury-Building and Codes-Fire Marshal
742 Bay Road-(518)761-8256 Building (518)761-8206 Fire Marshal
Case Number: SEP-0322-2019 Case Module: Permit
Inspection Date:Fri Jun 7, 2019 Inspection Status:Failed
Inspector: John O'Brien Inspection Type: Septic
Job Address: 62 REARDON RD Parcel Number: 289.7-1-14
Queensbury, NY 12804
Contact Type Company Name Name
Applicant Wassey, Herbert
Primary Owner Wassey Family, Inc.
Engineer Hutchins Engineering
Contractor Hilltop Construction
Granted Permission Wassey Family, Inc.
Checklist Item Passed Comments
Building Inspector Notes NO 6/7/19 Septic System Not Approved
Remaining Items:
-Final Electrical inspection
-Tom Hutchins Final Report
Type of Water: Municipal/Well Water YES Well
Well separation distance YES All neighboring and own wells are more than 100'from
absorption bed.
Absorbtion Fields:Total Length YES 70'
15'x25'Absorption Bed
Length of Each Trench YES 3 @ 20'
Jun 07,2019 (Page(1)
s +.:INSPECTION WORKSHEET (SEP 003379 1 209)
Checklist Item Passed Comments
Depth of Trenches YES 24"-36"
Stone Size: YES #2
Building to Tank YES 4"sch40 pvc From House To Pumpstation
2"Plastic Forcemain To 4"sch40 pvc at top of hill From
Pumpstation to Septic Tank.
Tank to Distribution Box YES 4"sdr35 pvc
Distribution box to Field/Pit YES 4"sdr35 pvc to 4"sdr35 pvc perforated with end looped
End Cap YES End looped
Foundation to Tank YES 11'
Foundation to Absorption YES 21'
Engineer Report and As-Built NO 6/7/19 Septic System Not Approved
Remaining Items:
-Final Electrical Inspection
-Tom Hutchins Final Report
System Use Status NO 6/7/19 Septic System Not Approved
Remaining Items:
- Final Electrical Inspection
-Tom Hutchins Final Report
nen, o n nspector
Jun 07,2019 Page(2)
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: 6 September 2024
To: Herbert Wassey
(Applicant)
Re: System Inspection Site Report for:
62 Reardon 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 , 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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