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PT-0731-2021 Property Transfer Sewage Disposal Information Form Date: 742 gay Road,Queensbury,NY 12804 P:518-761-8256 www.gueensbury.net (Name of Owner/Applicant) Re: Onsite Wastewater Treatment System Inspection Information Request for: (Site AddAss for Inspection) 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 l6formation.form, which must be completed, signed and returned to this office, with the appropriate fee(s)and docurmentatiori, prior to.scheduling an inspection. Please note the Town of Queensbury's fee for this service is$275. 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 15t of the current, or following year (whichever comes first), a map locating the septic system and payment totaling$2275 ($2000 refundable deposit plus$275 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, lot David Hatin, Director Building and Code Enforcement Town of Queensbury Property Transfer Packet Revised April2021 Office Use.Only Permit#: -'..D-161— 202( Tiron of[ ansbur Fee: $ 2 . 742 Bay Road,Queensbury,NY 12804 P:518-761-8206 or 518-761-8205 Invoice#: �� www.aueensbury.net SEWAGE DISPOSAL SYSTEM INSPECTION INFORMATION Individual Residential Wastewater- Treatment System CONTACT INFORMATION (please print legibly or type and include an email address), Property and Owner Information: (Please attach property survey or tax parcel map) Property address for inspection: uo �► Ovr Tax map number: .a w Property owner: Mailing Address(c/s/z): f J a 1 Cell#: ''��� '����1� Land Line#: Email: p1ECcEaW [E Applicant(if different than above): OCT 0 4 ZOZi Mailing Address(c/s/z): TOWN OF QUEENSBURY Cell M Land Line#: BUILDING& CODES Email: ❑Proposed Owner ❑ Realtor ❑ Attorney ❑ Other(explain: ) Septic Contractor: 4 Mailing Address(c/s/z): 2 L.-We� kk-V�1►% ��' 0�'� �,� �� � Cell#: Land Line#: Email: Reason for Inspection Request: ❑On the market ❑Future listing Ef Sale Pending ❑Deed Transfer Other: Property Transfer Packet Revised April 2021 HOUSEHOLD INFORMATION **PLEASE SEE SEPARATE PAGE FOR EXEMPTIONS** # Bedrooms #Bathrooms # Kitchens Jacuzzi tubs) 'Garbage grinder Onsite Wastewater Treatment System: How many systems are on the property? Year system(s) installed: Tank St 043 Size of Septic Tank f Type of Absorption System: Are all system components wholly within the property boundaries? [des ❑ No Are system plans availableT. ❑ Yes . p,-No Does the system(s) serve multiple properties? ❑ Yes [YVo- Jf yes; describe Maintenanc6: Service agreement? ❑ Yes U/N o; If yes, business' name Date of last inspection "014—i- N/A❑ Date tank last,pumped 7 r—i N/A❑ Frequency of pumping N/A❑ 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 QrNo Seasonal ponding or breakout of leach field? ❑ Yes YNo Property Transfer Packet Revised Aprii 2021 Statement of Acceptance of Conditions: I agree to: • Ensure that the septic tank(s), distribution box(,es), and/or seepage pits), ifEany, 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,.repres,entative present at.the site; • Allow the inspector to verify infformation 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=a'nd I acknowledge the following: After 1 year from date of submission and rthere is no activity on this permit, the,permit will expire and will be subject to submission of a renewal application-and-payment of the'rehewal 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. Si nature of'`'roe 3' .Y r �'g p p rty owner o'r authorizedagent: Affiliation: Downer .p agent ❑other: Please print name: •iC -- Signature: A V_ Date: Prior to scheduling with the Town 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 Queensburjrs' Code Enforcement Officer:``j 2. Expose=inlet andbutlet of septic tank, and/or pump station, exposed=box;expose any seepage pit covers. 3. Excavate test hold'1n-leach field if there is no d-box. 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James T.Soon n Lxo•IPnf 1E•f .wmrax laatloL v.r�'w,llrnntk.ry,µrYot • - i=rm��r �W a.n.:Lw Ito xme<L�r�r ar,r L .0 ouo.o owntivR xr r:/a1 28714-01-S1 au Nu:ehlne EnD1n33fino ('ti7iu 3 " Town of Queensbury Building&Code Enforcement SPc>o U.-.1 �� � 4�&L— - Offtce No.(518)761-8256 Ti;cA Septic Inspection- Report R E-6 t0G %3 t%A 1 Inspection request received: t�j 16120 6 Name: Inspected on: 17—720---t EL Location: 110 Arrive: p.m. Permit No.: Inspector's Initials C m nts and/or dia ram Soil Type: Sand I Loam/Clay Type of Water.-Municipal/Well Water Waterline separation distance ft. Well separation distance fL Other wells:, fL Well Casing Length 5W+!- Y N—N/A [15(Y to well required if NO] Absorption Field: Total length fL Length of each trench it Depth of trenches ft. Size of Stone Seepage Pits: Number Size: x Stone Size: Piping Size Type Building to tank Tank to Distribution Box Distribution Box to Field/Pit now Opening Sealed: End Cap Inleyoutlet Pipes&Baffles Manholes 127 or less below grade _Y—N . [provide extension collar if Yes] Y N Location I Separations Foundation to tank fL Foundation to absorption Separation of Pits fL Conforms as per Plot Plan _ NG re� �� Engineer Report and As-Built _`N T ETU Maintenance Contract provided —Y_NJ�� � " Location of System on Property: Front Re Left Side Right Side Middle Front . Middle Rear System Use Sta s: —� A� � cc Approved Partial Approved and needs to be re-inspected,please call the Building&Codes Office Disapproved Septic Inspection Report