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2024-0412 perty_Transfer Sew a Disposal Information Form IIECEOWE Town ofQcensbury AUG 07 2024 742 Bay Road,Queensbury,NY 12804 Date: v/3/ 2 P:518-761-8256 www.queensbury.net TOWN OF QUEENSBURY BUILDING &CODES o• / (Name of Applicant) Re: Onsite Wastewater Treatment System Inspection Information Request for: Drcari 6 Rd s , &Uee cbvn /k /2 °4' (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,0./ifQ ,1 John O'Brien, Director Bujding and Code Enforcement Town of Queensbury Property Transfer Packet Revised September 2023 Office Use Only Permit#: ,e)41,2 Town ofQmcensbury Fee:_$4►5:O® 742 Bay Road,Queensbury,NY 12804 P:518-761-8206 or 518-761-8205 Invoice • 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:60 b1 Crr Lake, Rd g k by AIY' 12SP y Tax map number:s,2 l D 9-.7q a /? / - / Current owner: KerniCrr) Mailing Address (c/s/z): G1i 5tierr< h. it Q1 AY Izgov. Cell #: 5 )S 7 2 Land Line#: r' Email: j�ke, harion e covii Applicant (if different than above): 50 rn S. above, Mailing Address (c/s/z): Cell#: Land Line#: Email: ❑ Proposed Owner ❑ Realtor ❑ Attorney ❑ Other (explain: Septic Contractor: gGIs'11710 �Lt.) $'eTij/CC- Mailing Address (c/s/z): Po x /,I , rA Y /2goi Cell #: Land Line#: clg 792_ 72-57 Email: Reason for Inspection Request: ❑On the market Et Future listing ❑Sale Pending [' Deed Transfer ['Other: Property Transfer Packet Revised September 2023 I HOUSEHOLD INFORMATION **PLEASE SEE SEPARATE PAGE FOR EXEMPTIONS** # Bedrooms - # Bathrooms 2- # Kitchens Jacuzzi tub(s) 0 Garbage grinder 0 Onsite Wastewater Treatment System: How many systems are on the property? I Year system(s) installed: Tank 1 Size of Septic Tank MType of Absorption System:P7 /l Are all system components w .Ily within the property boundaries? s ❑ No Are system plans available? Yes El No Does the system(s) serve multiple properties? El Yes 12 1 o If yes, describe ): Maintenance: Service agreement? El Yes ❑ No; If yes, business' name Date of last inspection N/A IEDate tank last pumped N/A ©- Frequency of pumping N/A 0� List known repairs/replacements, with dates: Date Type of Repair/Replacement Operation: System problems? ❑ Yes erho • Sewage odors? ❑ Yes. [+'No • Direct surface discharge(s)? ❑ Yes [1lo • Back-up of toilets? ❑ Yes Rico • Back-up of any other fixtures? (e.g. slow drains) ❑ Yes [+ iqo • Seasonal ponding or breakout of leach field? El Yes R iO Property Transfer Packet Revised September 2023 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): DIA) /)�r Please print name: /4, 8„--4,e-) Signature: Date: g 7 2 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 �70Wn o f Queen.sitiry BUILDING and ZONING DEPARTMENT Bay and Haviland Road. R.D. 1 Box 98 Oueensbury. New York 12801 SEPTIC DISPOSAL SYSTEM INSPECTION i NAME 60-4 — A-.744i&---0,0Z._ LOCATION rekolt ( , DATE g j 7PERMIT NO. g SOIL TYPE Sand Loam - Clay - Percolation Test Required? YES - NO Percolation rate - Min/Itch ,.„ -- i . --` 4/17-C7 til TYPE of SYSTEM:: Absorption field, total length Length of each trench Depth Of trenches . Size of gravel _____p SEEPA?af & N�g�E �' �.t Ef G ' . ~� S . 1 r471 e Bldg. to tank AUG 07 2024 Tank to disc. box gist. box to field l'OW t O ��s-.i EENSBURY Openings sealed? YES NO Partial BUILDING &CODES __.-.,,- LOCATlpN/SEPARATIONS= f t. Foundation to tank Foundation to absorption .:17 . Absorption to lot line - ft. Separation of pits ''."4. • OF SYSTEM M ON P ERTY(circle one) Front Rear Left side - Right side ,. 5: . . _ . . • . .....______....., A=fjp,...j. ....cL..."Ec. T Onz- !kJ a.) .- - ........„ ar Re It itzt c e;Li cil old --1 , 1 - 113d g rn 4 _...t,, ..... _..... _ 11 S El, 1 • T 1 E;IilUG, 07224E1 T...__ Trz..,,..,,. ...) ....„ r i *-.... 40 r <...... 1 , 13 4" 0 i r 61g? ( 4 1 itpf . , '1/4., ..........0/4\ sEfni a -TA-Awls I <N06 1 a i.. .....000, SVerAle I AN*/ s 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: 11 October 2024 To: Keith Barton (Applicant) Re: System Inspection Site Report for: 60 Dream Lake Road South, 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 from26 September 2024, the date of the inspection. Sincerely, A John O'Brien, Director Budding & Codes Enforcement Town of Queensbury /kd Revised August 2023