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PT-0452-2020 " r, Office Use Only z. Permit#: P 1 V452- Torn a olCeniburp: Fee: 4 ,/Q 742 Bay Road,Queensbury,NY 12804 20. 2- P:518-761-8206 or 518-761-8205 Invoice#: �JJ 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: 195 Assembly Point Road, Lake George,NY 12845 Tax map number: 226.19-2-1 Property owner: Frink Family Revocable Trust Mailing Address (c/s/z): 41 Schermerhorn Road, Cohoes,NY 12047 Cell#: 518-441-5817 Land Line#: 518-867-4111 Email: cgfrink@northeast-is.com **PLEASE SEE SEPARATE PAGE FOR EXEMPTIONS** Household Information: #Bedrooms 3 #Bathrooms 2 #Kitchens 1 Jacuzzi tub(s) 0 Garbage grinder 1 Onsite Wastewater Treatment System: ) LE E \‘q LE ) How many systems are on the property? 1 .-.l Year system(s) installed: Tank 1975 Size of Septic Tank AUG O 7/ 2O2Q Type of Absorption System: TOWN OF QUEENSBU Ry Are all system components wholly within the property boundaries? ©Yes ❑ BUILDING CODES Are system plans available? ❑ Yes El No Does the system(s) serve multiple properties? ❑ Yes ® No If yes, describe . . . ... z�i . . t. . : _. : _ - Maintenance: Service agreement? ❑ Yes ® No If yes,vendor name Date of last inspection N/A ® Date tank last pumped N/A El Frequency of pumping N/A IN Property Transfer Packet Revised October 2019 List known repairs/replacements, with dates: Date Type of Repair/Replacement Operation: • 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: 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 arid 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 permits the permit will expire and will be subject to submission of a renewal application andpayment 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: Charles G. Frink, Trustee Affiliation: 1 owner X e Fri Family Revocable Trust Signature: ( Date: 8/3/20 Prior to scheduling with the To n of Queensbury,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;outletof septic;tank, and/or pump station,_expose d-box, expose any seepage pit covers. ': ! s 3. Excavate test hole in leach field if there is no d-box. Property Transfer Packet Revised October 2019 8/7/2020 Google Maps Google Maps 195 Assembly Point Road,Lake George,NY 12845 • { t n ,t Cre° a f �, ! rA‘ 51 k rti "� ! 43i z¢ I a + • 1. • } F + �{ 'f' $,,, '},T r ',1k{ FtTr 9a• y 4..,rJ l4y +a- ¢-. i+' x a 1•t f ,1. 'b• rs ' t a k, hi a lv rt "}w•ro• s� , ,J' av, 9a`I" :° I° x • � . qr .X rt- ,r6 0 , ' d t.,t +a<r •A au•'p+'tlS„r.+'*''^'w Tu;r.,ia• ; C'v. �, !P�t r Yr�" ri4 ,. `r•`F �j1 a o 1. t 4 a,.rH ^�.a '" x „ ! a.r g• z • t ^•a ( r 1,'y.a , P S�'"'K,�p a '}` ��. ' . • '4••,• t•' .t rrt. le:t," 4.s. 3� >' rZi • '.4t 1 .x'y ,}• wv '+ tT' -t ..t7 C"rl ' } tl SSa t1" is a z , `''t i Y •. it ; ., r' 1j� * z ,.a,u-k 4R! e a* r„e'''' .. tr ';ita •,y ,Y I q:; 3 tr ',. ya. ,,� • I p 1 t;' , t. q-,.p4 �„.„tr",0,,,,t,: • 'i . L�tir ,Ta 4 .•w:. � ! am M1• .. . pr! 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