application Property Transfer Sewage Disposal Information Form
is
Date: c)1 J
Town oft? sbwrry c� �r��
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net (y�
i d.e ett&. GI -I' rd &C t fIrkinerfictE'Ctt-tny
(Name of Owner/Applicant)
Re: Onsite Wastewater Treatment System inspection information Request for:
y-7 Palmer brute, C .. 5.bc ii , nay
(Site Address) J
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,
4 11JFEB28 2020
David Hatin,Director TOWN C) : �� • !
Building and Code Enforcement €�F it_"r1;5=^ c; f
Town of Queensbury -N
Property Transfer Packet Revised February 2020
Office Use Only
Di Permit#: f:i� - pg.-1-�o010
[MOT t t j Fee: L42.a °
FEB 2� 202�
742 Bay Road,Queensbury,NY 12804
P:518-761-8206 or 518-761-8205 �� E OW 'F QU �c2,0z- Invoice#:
wttat�►:etueensburb�:rtet BUILDING
SEWAGE DISPOSAL SYSTEM INSPECTION INFORMATION
Individual Residential Wastewater Treatment System
Property and Owner Information: (Please attach property survey or tax parcel map)
Property address: P4 ad f r
Tax map number: 3i tp
Property owner: ' S' 'e .1--e_ &Cal &icrerei J itiltarypict eketarvc
Mailing Address(c/s/z): ei® (LSpektor.:761)1a5 ) )& _ , .
Cell#: Land Line#: �'^ ��Q `- I fit'
Email: SuzAnnt ioiy .,MCI t'Y1 (, �C e- ir hag 5
**PLEASE SEE SEPARATE PAGE FOR EXEMPTIONS**
Household Information:
#Bedrooms. o0 #Bathrooms I #Kitchens Jacuzzi tub(s) 0 Garbage grinder 0_
Onsite Wastewater Treatment System:
How many systems are on the property?
Year system(s)installed: Tank ? _ Size of Septic Tank 100(") edeij l
Type of Absorption System: ?
Are all system components wholly within the property boundaries? Yes El No
Are system plans available? 0 Yes -IN No
Does the system(s)serve multiple properties? 0 Yes No
If yes,describe
Maintenance:
Service agreement? ❑ Yes ❑ No If yes,vendor name I ,
Date of last inspection N/A ❑ Date tank last pumped a 15N/A ❑
Frequency of pumping rSN/A ❑
Property Transfer Packet
Revised October 2019
List known repairs/replacements,with dates:
Date Type of Repair/Replacement
AVI
Operation:
• System problems? Yes X No
• Sewage odors? Yes > No
• Direct surface discharge(s)? Yes )r No
• Back-up of toilets? Yes k No
• Back-up of any other fixtures?(e.g. slow drains) Yes )r No
• Seasonal ponding or breakout of leach field? -Yes k No
Statem nt of Acceptance of Conditions:
'Uf CY1Q{�'Ct'�C4r628.�0
:
• 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: cIretteas,r02ineCti x,
r
Affiliation: owner agent Exe cid&i)
Signature: Jbdiet j/'��, _ L 0 Date: cilialjaa
Prior to scheduling with the Town of Oueensburv,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
EXEMPTION CONDITION OPTIONS
Due to one of the conditions listed below, I am requesting an exemption from the
Septic Inspection Upon Property Transfer by the Town of Queensbury:
❑ The property to be sold or transferred will not be inhabited, and the new owner plans to demolish the
existing structure.In order to qualify for the exemption, a notarized affidavit must be submitted to the
Building and Codes Enforcement Office stating that the dwelling will not be inhabited and that it will be
demolished with no immediate plans to rebuild or the dwelling will not be inhabited,it will be
demolished and rebuilt, in which case the affidavit shall be accompanied by a site plan,including
adequate detail to demonstrate a lawful OWTS,together with a check payable to the Town of
Queensbury in the amount of$2,000. Such funds will be held in a non-interest-bearing escrow account
and will be released,in the former case,upon issuance of a demolition permit and,in the latter case,
upon issuance of a certificate of compliance from the Building and Codes Enforcement Office.If the
Property Transfer inspection is not completed within that 6 (six) month timeframe,
the $2000 will be forfeited.
El An OWTS inspection was not able to be completed prior to the conveyance of real property due to
inclement weather. In order to qualify for the exemption, a notarized affidavit from the new property
owner to complete the requisite OWTS inspection within six months of the date of the conveyance of
real property,or June 1,whichever comes first,must be filed with the Building and Codes Enforcement
Office.A check payable to the Town of Queensbury in the amount of$2,000 will be held in a non-
interest-bearing escrow account and shall be released upon the completion of a satisfactory OWTS
inspection from the Building and Codes Enforcement Office. If the Property Transfer
inspection is not completed within that 6 (six) month or June 1st timeframe the
$2000 will be forfeited. '
❑ The property to be sold or transferred contains an existing OWTS that does not comply with the
provisions of this article, and the prospective purchasers and/or the Seller wish to forgo an inspection
in favor of installing an approved OWTS within six months of the transfer of property. In order to
qualify for the exemption, a notarized affidavit must be submitted to the Building and Codes
Enforcement Office stating that the existing OWTS will be replaced within six months from transfer of
property. The affidavit must be accompanied by a site plan, including adequate detail to demonstrate
that the replacement OWTS will comply with this article,together with a check payable to the Town of
Queensbury in the amount of$2,000. Such funds will be held in a non-interest-bearing escrow account
and will be released upon issuance of a certificate of compliance from the Building and Codes
Enforcement Office. If the Property Transfer inspection is not completed within that 6
(six) month timeframe, the $2000 will be forfeited.
Property Transfer Packet
Revised October 2019
❑ During the OWTS inspection, a failure of the septic system was determined. Due to winter and
frozen conditions,the repair to an existing OWTS could not occur or a new OWTS could not be
installed before the conveyance of real property. In order to qualify for the exemption,a notarized
affidavit from the new property owner to complete the installation or repair of the septic system within
six months from the date of the conveyance of real property, or June 1,whichever comes first,must be
filed with the Building and Codes Enforcement Office.A check payable to the Town of Queensbury in
the amount of$2,000 will be held in a non-interest-bearing escrow account and shall be released upon
the completion of the repair or installation of a new septic system and a satisfactory OWTS inspection
from the Building and Codes Enforcement Office. If the Property Transfer inspection is not
completed within that 6 (six) month or June 1st timeframe, the $2000 will be
forfeited.
❑ There is arecord of a septic system inspection upon property transfer permit and inspection completed
and passed within the last three years. Please provide a copy of this record.
PLEASE READ NOTICE THOROUGHLY:
Failure to complete the inspection, obtain the permit or complete all repairs/installations
identified in the preceding subsections of this section within the time provided or any subsequent
deadline established by the Building and Codes Enforcement Office will result in forfeiture of the
moneys held in escrow, and the Town may use such funds toward abating the conditions caused
by each such violation of this article.
Inspections must take place within one(1) year of submission of a completed application.
Inspections scheduled to take place after the one year period will be subject to submission
of a renewal application and payment of the renewal fee based on the current fee schedule.
I have read and understand the above notice regarding the expectations and possible forfeiture
of moneys submitted to the Town of Queensbury for an exemption request.
Seller: t�
Print Namema taro, Cc a q ,, Date: 0poao
Sign Name: dAgAty( , Date:
4a-41W
Buyer: `1
Print Name: cJo K P. Cris3, g.ew,Lrric,vr�r of JP(7ros5 ono-e.-��c.- Date:
Sign Name: f Date:Property Transfer Packet
Revised October 2019