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application --) 1 0 Office Use Only r .-ter----,-: -\:' i it © E Permit#: Pi- 0 24-2 2431 APR 2 4 2019 Fee: 2W 742 Bay Road,Queensbury,NY 12804 t��e P:518-761-8206 or 518-761-8205 TOWN OF QUEENSBURY Invoice#: www,uueen b4sr ,n t BUILDING& CODES SEWAGE DISPOSAL SYSTEM INSPECTION INFORMATION Individual Residential Wastewater Treatment System Property and Owner Information: (Please attach property survey or tax parcel map) Tax map number:Property owner: (]Jiu'du 6c'S e --1-04 Seog ii-krtishOYL Mailing Address (c/s/z): l/ f r%3 gaitid Ef 4/ aalensAil NY&& . Cell#:J10 o a Cos- Land Line#: Email: C'Oe_VS-/-M"t A l a CJ q ma.'L . co V14 Household Information: - l #Bedrooms #Bathrooms 3 #Kitchens ./ 1G `� / Onsite Wastewater Treatment System: How many systems are on the property? Year system(s)installed: Tank ? 902. Size of Septic Tank lbd O Type of Absorption System: T�k a/Ad Lezt.C/i 1?fid Are all system components wholly within the property boundaries? /Yes No Are system plans available? ✓Yes _No Does the system(s)serve multiple properties? Yes ✓No If yes,describe Maintenance: Service agreement? ✓ Yes No If yes,vendor name 'Q S Date of last inspection N/A Date tank last pumped /20/5 N/A Frequency of pumping ea-vil N/A Property Transfer Packet Revised March 2019 List known repairs/replacements,with dates: Date Type of Repair/Replacement . h5eT cl./d I'd Operation: • System problems? Yes VNo • 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 7 No • Seasonal ponding or breakout of leach'field? Yes ''No _ 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 clej ere, J,4'7 i 'g • Have anauthonze represen a we pr sent a e s' e, ��� p �Q`-evg�Gx /11dZ-�1-A-ke-seatj • Allow the inspector to verify information provided above,and to conduct an inspection of the htluILS 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. I agree to be responsible for inspection fee payment. Signature of property owner or authorized agent Please print name: ( / /at& '- _' 4 ./) Affiliation: 1/ owner agent Signature: re Date: ��1/ 2-0/ Prior to schedulin h the Town of Oueensburv, you MUST: 01. 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. Property Transfer Packet Revised March 2019 Property Transfer Sewage Disposal Information Form ---,- Town of Queensbur VZ-,/ 2D/9'Date: 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 w _9t lee!,sbur.net (") To: ( 1&Vott t/��f�/l C D T./ rWC 7Z r' (Name of Applicant) Re: Onsite Wastewater Treatment System Inspection Information Request for: cad eca/ &u., s/ orq L/ /z 8JV (Site Address)-' Thank you for requesting an inspection for the onsite wastewater treatment system 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 advance information.to us about the site. Prior to our inspection, we request information regarding the property and the onsite wastewater treatment system (septic- system) on that property. We also would like to confirm property access and that pre-inspection system preparation will be completed prior to our arrival. Enclosed is a Septic System Inspection Information form, which must be completed, signed and returned to this office prior to scheduling an inspection. Following completion of the inspection,you will be sent a System Inspection Site Report. The System Inspection Information Request and the System Inspection Site Report are standardized forms used by the Town of Queensbury. Please note the Town of Queensbury's fee for this service is$250. Be advised that all fees for services must be paid prior to the site inspection. We require 48 hours notification prior to inspections. If you have any questions, please call. You may FAX or email the completed Septic System Inspection Information form back to us. If the purchaser is requesting an exemption, please submit this application along with a notarized letter stating the septic system will be inspected or repaired within 6 months of the date of this application or June 1st of the current, or following calendar year (whichever comes first), a map locating the septic system and payment totaling$2250 ($2000 refundable deposit plus-$250 permit fee). Phone: (518) 761-8256 Fax: (518) 745-4437 Email: kated@queensbury.net Thank you. Sincerely, (-3j4 David Hatin, Director Building and Code Enforcement Town of Queensbury Property Transfer Packet Revised March 2019