PT-0398-2021 Property Transfer Sewage Disposal Information.Form
Date:
Town of Queensbury
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.gueensbury.net -
(Name of Owner/Applicant)
Re: Onsite Wastewater_Ti eatment System Inspection Information Request for:
'Spit
(Site Address 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 foe-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) and documentation, prior to scheduling an inspection..
Please note the Town ofrQueensbury'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 1" 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,
David Hatin; Director
Building and Code Enforcement
Town of Queensbury
Property Transfer Packet Revised April 2021
Office Use Only
Permit#:
Totim arcuw n, Fee: -
742 Bay Road,Queensbury,NY 12804
P:518-761-8206 or 518-761-8205 Invoice#: �
www.gueensbury.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: r ld Q4e.F.,n, IIuq
Tax ma number: Q 3 4 op S p S � 9
Property owner: -b �Lsbr;z C ;)cyPk
Mailing Address (c/s/z): C20 Pin&rmn- e v it- &S+ 6'rzahbu5�) )' UL Q i
Cell#: rj18-33 --8/�1 Land Line#: 518 -33�-SI�1
Email: Ck;Ldrase& M�j Cep. t-r• C0fN" C
DEEOWE
Applicant (if different than above): MAY 2 7 2021
Mailing Address (c/s/z): TOWN OF QUEENSBURY
Cell #: Land Line##: BUILDING&CODES
Email:
❑Proposed Owner ❑ Realtor ❑ Attorney ❑ Other (explain: )
Septic Contractor: L,BS 5i?P+kG bIr-A Cav(Gc
Mailing Address (c/s/z): cQ l.*Wer
Cell#: Land Line#: 512 - 'Iqg- $Igo
Email: Iles lbs2 lC, co a&
Reason for Inspection Request:
On the market ❑ Future listing ❑Sale Pending ❑ Deed Transfer ❑Other:
Property Transfer.Packet Revised April 2021
HOUSEHOLD INFORMATION .
"PLEASE SEE SEPARATE PAGE FOR EXEMPTIONS"
# Bedrooms_�# Bathrooms�_ # Kitchens Jacuzzi tubs) 6 Garbage grinder a
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? Yes ❑.No
Are system plans available? ❑ Yes No
Does the systems) serve multiple properties? ❑ Yes '� No
If yes, describe
Maintenance:
Service agreement? ® Yes ❑ No; If yes, business' name
Date of last inspection. a0) N/A ❑ Date tank last pumped 10 1410 N/A ❑
Frequency of pumping 3 L{rs N/A ❑
List known repairs/replacements, with dates:
Date Type of Repair/Replacement
Operation:
System.problems? ❑Yes - 2. No
Sewage odors? ❑ Yes .No
. Direct surface discharge(s)? ❑ .Yes : [R.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 LK No
Property Transfer.Packet Revised April 2021
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:
Affiliation: g]owner ❑agent ❑other
Please print name: '1,4rose
Signature: �• Date: S� /may
Prior to schedulink 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 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 April 2021
289.14-126 PT-0398-2021
Childrose, Doug
97 Fitzgerald Rd
Property Transfer
�w
MAY 2 7 2021 �
TOWN OF QUEENSBURY
BUILDING & CODES
HART ENGINEERING
RESIDENTIAL, COMMERCIAL&MUNICIPAL SITE DESIGN & DEVELOPMENT
1969 FERNDALE ROAD CASTLETON, NY 12033
(518)479=4014 FAX(518)477-6371
STEVEN P.HART;P.E.
Town of Queensbury October 15,2021 .
742 84y Road
Queensbury;New-York 12804
Attn:Mr.Mark:Siriith, Code'Enforcement Officer
ke: Childrose Septic System-Replacement
9.7 Fitzgerald Road-Town of Queensbury
-Dear Mr. Smith:
With:respect to-the:above replacement septic field.installation,we offer you the following
information:
1. As Built drawing as provided by the Owner,and
2. Material list.spec sheets M provided by the Contractor; Mr..Chris.Bell.
With respect to the provided information as noted above, it appears that the holding tanks
and related appurtenances were installed.in'substantial conformance to the approved
plans:
It isjmportant to note that Hart Engineering did not perform any construction
inspections during,.or after;.the construction process. We were-not aware that thus was a
requirement and therefore did not perform these services. Our conclusion of"substantial
conformance"is based on conversations with the Contractor during construction and with
the owner following construction: -
Should you.have any questions_or:require additional information please feel free to.
contact us.
Very truly yours-,
` Hart Engneerirrg,
teven P. Hart,P.E.
cc:File:childrosequeensbury2l-I