application Property Transfer Sewage Disposal Information Form
Town of Queensbury
Date: IV \ Z o ilzt
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensburv.net
De_Lai se. - Cit CA )r- nevirrt-
(Name of Owner/Applicant)
Re: Onsite Wastewater Treatment System Inspection Information Request for:
c 3 Ca �ta j(� rt.r� c le_v�.—d i 1'J `� 1 2� ?_O
(Site Address) v
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 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), 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 lst 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,
1r
David Hatin, Director
Building and Code Enforcement
Town of Queensbury
Property Transfer Packet Revised September 2019
e 6
Office Use Only
Permit#: ' O $ o - 2015
Tom dUjccnsbuzy Fee: 23
742 Bay Road,Queensbury,NY 12804
P:518-761-8206 or 518-761-8205 Invoice#:
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: �'0�� 6 � Ai/
Tax map number: 07 3 9 /- 3 3
Property owner: (De cr C/a �rcar
Mailing Address(c/s/z): 5— P 2,,e4 ue:-?,_-jea�2/ ,4 / ?e,/
Cell#: S I,Q^ zfV/-6// 7 Land Line#:
Email: ./�j l, Q rr,c,/0 (°_:ym[v/ ( r
**PLEASE SEE SEPARATE PAGE FOR EXEMPTIONS**
Household Information: ' Q
#Bedrooms oZ #Bathrooms / #Kitchens i
Onsite Wastewater Treatment System: ®C� 0 9 �0�9
How many systems are on the property? TOWN OF QUEENSSURY
Year system(s)installed: Tank Size of Septic Tank BUILDING&COUPS
Type of Absorption System:
Are all system components wholly within the property boundaries? ❑Yes ❑ No
Are system plans available? 0 Yes 0 No
Does the system(s)serve multiple properties? 0 Yes 0 No
If yes,describe
Maintenance:
Service agreement? ❑ Yes l( No If yes,vendor name
11P
Date of last inspection N/A 0 Date tank last pumped tul iv N/A ❑
Frequency of pumping N/A 0
Property Transfer Packet Revised September 2019
List known repairs/replacements, with dates:
Date Type of Repair/Replacement
Operation:
• System problems? Yes ✓No
• Sewage odors? Yes , No
• Direct surface discharge(s)? Yes No
• Back-up of toilets? Yes ✓ No
• Back-up of any other fixtures? (e.g..slow drains) Yes ." No
• Seasonal ponding or breakout of leach field? Yes —7"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.
I agree to be responsible for inspection fee payment.
Signature of property owner or authorized agent
Please print name: e,.{-11 P-r,no4-
Affiliation: ' owner agent
Signature: Date: /o r
Prior to scheduling with the Town of Queensburv,von 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 September 2019