application •. Office Use Only
411114
Permit#: , 1 '�D •i ITarsiFee: 2c 0
74:lay Road,Queensbury,NY 12804 .,,CCZ�
P:513-761-8206 or 518-761-8205 Invoice#: 11�µ:,
www.ueensbury.net
SEWAGE DISPOSAL SYSTEM INSPECTION JN Formatted:Font:Not stalk )
Individual Residential Wastewater Treatment System Formatted:Left
property and Owner Information Please attach property survey or tax parcel map) Deleted'I
Property address: 26 Reardon Rd
Tax map number: 298.7-1-31
Property owner: Tim and Kim Larned
Mailing Address(c/s/z): 210 Wendy Court Schenectady,NY 12306
,cell #: 518-461-4021 Land Line#_ 519-355-9106 ,i Deleted`Telephone
{Deleted:
Email:
Household Information: 0 IE C kb II 1
#Bedrooms 4 #Bathrooms_3' #Kitchens 2_ JUN 0 6 201970
Onsite Wastewater Treatment System: T BU►LDING&C�SBURY
DES
How many systems are on the property?_2 tanks
Year system(s)installed: Tank 2001 Size of Septic Tank 1000 and 500-not positive size or age of tad
tank
Type of Absorption System:_Eljen
Are all system components wholly within the property boundaries? Yes No Unknown X
Are system plans available? X Yes 0 No
Does the system(s)serve multiple properties? X Yes No
If yes,describe system serves two buildings on the same property,main house and apartment over
garage_
Maintenance:
Service agreement? 0 Yes X No If yes,vendor name
Date of last inspection_2013 N/A Date tank last pumped_2013 N/A 0
Frequency of pumping_3-5 years N/A 0 last two years has very I i m i ted use
Property Transfer Packet Revised March 2019
List knowlinrepairs/replacements,with dates:risers put on tanks,date unknown.
Date a Type of Repair/Replacement
1
{Deleted:¶
Operation: Formatted:Normal
System problems? Yes X No
Sewage odors? Yes X No
Direct surface discharge(s)? Yes _X No
Back-up of toilets? Yes _X No
Back-up of any other fixtures?(e.g.slow drains) Yes _X No
Seasonal ponding or breakout of leach field? Yes X No
Statement of Acceptance of Conditions:
Formatted:Font:8 pt I agree to: (Formatted:Normal
• 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.
Formatted:Font:8 pt,Bold
To the best of my knowledge,the information provided above is accurate. _°° =
Formatted:Normal, No bullets or
I agree to be responsible for inspection fee payment. numbering
Signature of property o er or authorized agent
Please print name: Ari L-, J E C
Formatted:Font:8 pt
Affiliation: er agent Pat Seelye rr -
Signature: ` Date: Y
Pror to sch ulin&with the Tow of Queensbury,you MUST:
1. Se edule a sewage er 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
Deleted: SYSTEM INSPECTION
INFORMATION REQUEST I
• Individual Residential Wastewater
Property Transfer Sewage Disposal Information Form Treatment System
Formatted:Left
Towns of.
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net Date:
To: Tim Lamed
(Name of Applicant)
Re: Onsite Wastewater Treatment System Inspection Information Request for:
_26 Reardon Rd.Queensbury
(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
15t 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.
ECEIIVED
Sincerely, D
( 1341° pg0t JUN 0 b 2019
David Hatin,Director TOWN OF QUEENSBURY
Building and Code Enforcement BUILDING& CODES
Town of Queensbury
Property Transfer Packet Revised March 2019