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Property Transfer Sewage Disposal Information Form
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Date: I 'iP'
Town of Queensbury
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net
P1+14 C_iCk E. RA1 r oric,t ores m
(Name of Owner/Applicant)
Re: Onsite Wastewater Treatment System Inspection Information Request for:
5 acid\ c x\ Queensbury
(Site Address)
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 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 prior to 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) and documentation, 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 1st 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,
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David Hatin, Director 77,,
Building and Code Enforcement �/NOF
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Town of Queensbury �'NG cpL'U.
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Property Transfer Packet Revised February 2020
Office Use Only
37,
Permit#:
low! (Zwert.hun Fee: t 25 l
742 Bay Road,Queensbury,NY 12804
P:518-761-8206 or 518-761-8205 Invoice#: 2(0
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: W c o )r‘ +1-0,t Q oeen 5bu c y , N :y. 12-8 0 L/
Tax map number: 990 • 5- I - I '8
Property owner: Pc 4ric k, acky MOnc 't 110
Mailing Address (c/s/z):
Cell #: 2.22- 396,9 Land Line #: 5 I'S- Lio9 - 7(0 0.3
Email: P * Soce.gino @ vc,hOO 1 Com .
**PLEASE SEE SEPARATE PAGE FOR EXEMPTIONS**
Household Information:
# Bedrooms / # Bathrooms I # Kitchens I Jacuzzi tub(s) Garbage grinder 0
Onsite Wastewater Treatment System: /
How many systems are on the property?
Year system(s) installed: Tank I4O . Size of Septic Tank 7 50 9 cd
Type of Absorption System: Snr\a,
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 r
•
Maintenance: TOWN OF ..-,7
1
77 7'. �
Service agreement? ❑ Yes No Ifyes, vendor name BUILDING& L n►'
g QQ C'Ob=S
Date of last inspection N/A 1 1 Date tank last pumped 9-/�°-N/A ❑
Frequency of pumping N/A ❑ e%rm ye60-15
Property Transfer Packet Revised October 2019
List known repairs/replacements, with dates:
Date Type of Repair/Replacement
rt)
Operation:
• System problems? Yes ) No
• Sewage odors? Yes 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 No
• Seasonal ponding or breakout of leach field? Yes A 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
• 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 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 20%of the fee is retained by the Town of Queensbury.
Signature of property owner or authorized agent
Please print name: gqirywrIa . S o in O
Affiliation: X owner agent
Signature: gurt, K )ôtA.- ODate: 3- l'2.-02.0
Prior to scheduling with the Town of Queensburv, 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.
Property Transfer Packet Revised October 2019
PROPERTY TRANSFER SEWAGE DISPOSAL INSPECTION LETTER
Satisfactory Compliance Notice
742 Bay Road, Queensbury, NY 12804
P: 518-761-8256 www.queensbury.net
Date: 9 June 2020
To: Patricia & Raymond Soresino
(Applicant)
Re: System Inspection Site Report for:
5 Wagon Trail, Queensbury, NY 12804
(Site Address)
As requested, I have 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:
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.
Sincerely,
David Hatin, Director
Building & Code Enforcement
Town of Queensbury
Building & Code Enforcement January 2019