application Property Transfer Sewage Disposal Information Form
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Date:
Town of Qucensbury
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensburv.net
Van Schaick Lake House, LLC
(Name of Owner/Applicant)
Re: Onsite Wastewater Treatment System Inspection Information Request for:
11 Fielding Lane, Cleverdale, NY 12820
(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.Priorto 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 priorto
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 151 of the current, or following year (whichever comes first), a map locating the septic
system and payment totaling$2250 ($2000 refundable deposit
p yposit 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,
(""* A,4
'► DEC 0 1 ZOZ
David Hatin, Director
Building and Code Enforcement
Town of Queensbury
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742 Bay Road,Queensbury,NY 12804
P:518-761-8206 or 518-761-8205 Invoice tt:
www.queensburv.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: 11 Fielding Lane, Cleverdale, NY 12820
Tax map number: 227.13-2-15
Property owner: Van Schaick Lake House,LLC
Mailing Address(e/s/z): 17 Hydor Drive,Castleton, NY 12033
Cell#: (518)859-5879 Land Line#: (518)477-9328
Email: lauram25@nycap.rr.com
**PLEASE SEE SEPARATE PAGE FOR EXEMPTIONS**
Household Information:
#Bedrooms 3 #Bathrooms 2.5 #Kitchens I Jacuzzi tub(s) 0 Garbage grinder 0
Onsite Wastewater Treatment System:
How many systems are on the property? 1
Year system(s) installed: Tank 2000 Size of Septic Tank 1000 gallon
Type of Absorption System: Leachfield
Arc all system components wholly within the property boundaries? ®Yes ❑ No
Are system plans available? ® Yes 0 No
Does the system(s)serve multiple properties'? 0 Yes IXi No
If yes,describe
Maintenance: DEC 1 2020
Service agreement'? 0 Yes El No If yes, vendor name
Date of.last inspection N/A El Date tank last pumped N/A
Frequency of pumping NIA IRl
Prvreityl'rangfa Packet Rev,st-J October 2019