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applicationProperty Transfer Sewage Disposal Information Form Date:_(olis|(% ‘Town of Queensbury 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.queensbury.net toyvey Zr rf dey(Name of Owner/Applichnt) Re:—Onsite Wastewater Treatment System Inspection Information Request for:=Cicnardsan Cd. (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 advanced information about the site.Prior to our inspection,we request this completed application,a site map indicating the location of the septic components and confirmation the pre- inspection preparation (see the last page of this packet)will be completed priorto our arrival. Enclosed is a Septic System Inspection Information form,which must be completed,signed and returned to this office,with the appropriate fee(s),prior to scheduling an inspection. Please note the Town of Queensbury’s fee for this service is $250.Be advised that all fees must be paid prior to scheduling the inspection.We require 48 hours notification prior to scheduling the inspection. 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/replaced within 6 months from the date of the Property Conveyance or June 1*of the current,or following year (whichever comes first),a map locating the septic system and payment totaling $2250 ($2000 refundable deposit plus $250 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,Dab A k-David Hatin,Director Building and Code Enforcement Town of Queensbury Property Transfer Packet Revised September 2019 Office Use Onl remitt: PT: O60%-2015 Tove of Qocensbary Fee:_20 ~ 742 Bay Road,Queensbury,NY 12804 . P:518-761-8206 or 518-761-8205 Invoice #:_Z1 0.75 www.queensbury.net SEWAGE DISPOSAL SYSTEM INSPECTION INFORMATION Individual Residential Wastewater Treatment System Property and Owner Information:(Please attach property survey or tax parcel map) Property address:\Saw Tax map number:09.a-p-PPropertyowner:__fe ay ey sea Fs Sc Mailing Address (c/S/2):_2b QQoram QO Goeces Feld NY (2933 Cell #:|14135-3443 Land Line #:_SiG ~843-S/Q) Email: **PLEASE SEE SEPARATE PAGE FOR EXEMPTIONS** Household Information: #Bedrooms “2S #Bathrooms 2 #Kitchens _|__ Onsite Wastewater Treatment System: How many systems are on the property?_|__ Year system(s)installed:Tankgetet Size of Septic Tank 4606 ‘Type of Absorption System:Oy ude\\ Are all system components wholly within the property boundaries?Yes C1No Are system plans available?(Yes C1 No Does the system(s)serve multiple properties?ClYes GNo Ifyes,describe Maintenance: Service agreement?I Yes Mon vendor name Date of last inspection _N/A CI]Date tank last pumped ___N/A C1 Frequency of pumping___N/A Property Transfer Packet Revised September 2019 List known repairs/replacements,with dates: Date ‘Type of Repair/Replacement Operation: +System problems?Yes eo +Sewage odors?Yes__eo +Direct surface discharge(s)?Yes 60 +Back-up of toilets?Yes _i-No +Back-up of any other fixtures?(e.g.slow drains)Yes oN +Seasonal ponding or breakout of leach field?Yes one. Statement of Acceptance of Conditions: Lagree 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 1 year from date of submission and there is no activity on this permit,the permit will expire.In addition, if the permit is withdrawn 20%of the fee is retained by the Town of Queensbury. Signature of property owner or authorized agent Please printname:SilamDenaisor Affiliation:owner agent _Va Signature:LS Waa Onmrnide _Date:ofts/q Prior to scheduling with the Town of Queensbury,you MUS! 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. Property Transfer Packet Revised September 2019