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Permit#: -0(.0. 4c ' 202°
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742 Bay.Road;Queensbury,NY 12804
P:518-761-8206`or 518-761-8205 Invoice#: b
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SEWAGE DISPOSAL SYSTEM INSPECTION INFORMATION
Individual Residential Wastewater Treatment System
Property and Owner Information: (Please attach property survey or tax parcel map)
Property address: c /4 h/, P
Tax map number: 240 / - 2 7
Property owner: evee'fA ®rvir .T//
Mailing Address(c/s/z):
Cell#: Land Line#:
Email:.
**PLEASE SEE SEPARATE PAGE FOR EXEMPTIONS**
Household Information:
#?Behr oms f y; #Bathrooms 2 #Kitchens / Jacuzzi tub(s) — Garbage grinder
Onsite Wastewater Treatment System:
How many systems are on the property?
Year system(s)installed: Tank Size of Septic Tank
Type of Absorption System:
Are all system components wholly within the property boundaries? Dyes 0 No
Are system plans available? ❑ Yes 0 No I C t 11 ,�jz
u 1
Does the system(s)serve multiple properties? 0 Yes Ce'No 2 9 2020
OCT
If yes,:describe
Maintenance: , TOWN OF OUEENSBURY
BUILDING DES
Service agreement? 0 Yes 0 No If yes,vendor name
Date of last inspection. N/A 0 Date tank last pumped N/A
Frequency of pumping N/A D
Property Transfer Packet Revised.October 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 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: 6 ergra/ fe0`/,04
Affiliation: owner V agent /ter oipp eA ' p irc66_re.
Signature:�� �. Date: /92. 704,
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