PT-0435-2021 Property Transfer Sewage Disposal Information Form
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Date: Z
Town of Queensbury
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.ciueensbury.net
(Nam of O ner/Applicant)
Re: Onsite Wastewater Treatment System Inspection Information Request for:
Llot/e__ All SS�
(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 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) and documentation, 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 1n 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. LK
Sincerely,,t)J 4 David Hatin, Director
Building and Code Enforcement
Town of Queensbury
Property Transfer Packet Revised April 2021
Office Use Only
Permit#: + QAZ'5 '�Z
le!!R((twcn ry Fee:
742 Bay Road,Queensbury,NY 12804 2 Q
P:518-761-8206 or 518-761-8205 Invoice#: JC
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: (.(� �� -
Tax map number:17 0
Property owner: VA
Mailing Address(c/s/z):
Cell#: :57 r 1 3 Land Line#: ` Z 7/
Email: { a4o j i 1? CBk Mo
-
WN
Applicant(if different than above):
Mailing Address(c/s/z):
OF Cell#: Land Line#:
Email:
❑Proposed Owner ❑ Realtor ❑ Attorney ❑ Other(explain: )
Septic Contractor: 221:1Z V,/f C'
�Y �� 7Y
Mailing Address(c/s/z): 0 rY
Cell#: Land Line# 54) (1 2—753 t
Email:
Reason for Inspection Request:
❑On the market ❑Future listing ❑Sale Pending /Dee/dTransfer ❑Other:
Property Transfer Packet Revised April 2021
P
HOUSEHOLD INFORMATION
"PLEASE SEE SEPARATE PAGE FOR EXEMPTIONS"
# Bedrooms # Bathrooms 1 # Kitchens ( Jacuzzi tub(s) 0 Garbage grinder b
Onsite Wastewater Treatment System:
How many systems are on the property?
Year system(s) installed: Tank 70 z( Size of Septic Tank Ovo fl
Type of Absorption System: -1lil,*7 `ice�-
Are all system components wholly within the property boundaries? es ❑No
Are system plans available? Yes ❑ No
Does the system(s) serve multiple properties? ❑ Yes No
If yes, describe
Maintenance:
Service agreement?❑ Yes No; If yes, business' name
Date of last inspection N/A❑ Date tank last pumped 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 ❑ No
Seasonal ponding or breakout of leach field? ❑ Yes ❑ 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`Yo of the fee is retained by the Town of
Queensbury.
Signature of property owner or authorized agent:
Affiliation: owner ❑agent p other:
Please print name:
Signature: 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 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
RESOLUTION APPROVING JOHN HAMPSHIRE'S APPLICATION FOR
SANITARY SEWAGE DISPOSAL VARIANCE
RESOLUTION NO.: BOH 3,2021 5_ E C E O W E
INTRODUCED BY: Mr. George Ferone
WHO MOVED ITS ADOPTION JUN 0 2 2021 L,1
TOWN OF QUEE.NSBURY
SECONDED BY: Mr.Timothy McNulty L BUILUNG& CODES
WHEREAS,John Hampshire(Applicant) filed an application for a variance from provisions
of the Town of Queensbury On-Site Sewage Disposal Ordinance Chapter 136, §136-11, which
requires applicants to obtain a variance for holding tanks as the Applicant wishes to install a new
2,000 gallon septic holding tank in lieu of a sewage disposal system on property situated at 62
Dream Lake Road in the Town of Queensbury, and
WHEREAS,the Town Clerk's Office published the Notice of Public Hearing in the Town's
official newspaper and the Local Board of Health duly conducted a public hearing concerning the
variance request on Monday,January I I'h, 2021,and
WHEREAS, the Town Clerk's Office has advised that it duly notified all property owners
within 500 feet of the subject property,
NOW,THEREFORE,BE IT
RESOLVED,that
1. due to the nature of the variance, the Local Board of Health determines that the
variance would not be materially detrimental to the purposes and objectives of this
Ordinance or other adjoining properties nor otherwise conflict with the purpose and
objectives of any Town plan or policy; and
2. the Local Board of Health finds that the granting of the variance is necessary for the
reasonable use of the land and is the minimum variance which would alleviate the
specific unnecessary hardship found by the Local Board of Health to affect the
Applicant; and
BE IT FURTHER,
RESOLVED, that the Local Board of Health hereby approves the application of John
Hampshire for a variance from the Sewage Disposal Ordinance to install a new 2,000 gallon septic
holding tank in lieu of a sewage disposal system on property located at 62 Dream Lake Road in the
Town of Queensbury and bearing Tax Map No: 279.17-1-10.
Duly adopted this I Ph day of January, 2021,by the following vote:
AYES Mr. McNulty,Mr. Strough, Mr. Metivier, Mr. Freer, Mr. Ferone
NOES None
ABSENT: None
RESOLUTION APPROVING JOHN HAMPSHIRE'S APPLICATION FOR
SANITARY SEWAGE DISPOSAL VARIANCE
RESOLUTION NO.: BOH 57,2021
INTRODUCED BY: Mr.Timothy McNulty
WHO MOVED ITS ADOPTION
SECONDED BY: Mr. George Ferone
WHEREAS, John Hampshire (Applicant) previously filed an application for a variance
from provisions of the Town of Queensbury On-Site Sewage Disposal Ordinance Chapter 136,
§136-11, which requires applicants to obtain a variance for holding tanks as the Applicant wished to
install a new 2,000 gallon septic holding tank in lieu of a sewage disposal system on property
situated at 62 Dream Lake Road in the Town of Queensbury, and
WHEREAS, by Resolution No.: BOH 003.2021, the Local Board of Health approved the
Applicant's variance to install the new 2,000 gallon septic holding tank in lieu of a sewage disposal
system on the property located at 62 Dream Lake Road in the Town of Queensbury, and
WHEREAS, the Applicant has applied to the Local Board of Health for an additional
variance from Chapter 136, §136-11 to approve the already installed 2,000 gallon septic holding
tank 31.1±' from the Dream Lake shoreline in lieu of the required 50' setback,and
WHEREAS,the Town Clerk's Office published the Notice of Public Hearing in the Town's
official newspaper and the Local Board of Health duly conducted a public hearing concerning the
variance request on Monday, September 27`h, 2021, and
WHEREAS, the Town Clerk's Office has advised that it duly notified all property owners
within 500 feet of the subject property,
NOW,THEREFORE, BE IT
RESOLVED,that
1. due to the nature of the variance, the Local Board of Health determines that the
variance would not be materially detrimental to the purposes and objectives of this
Ordinance or other adjoining properties nor otherwise conflict with the purpose and
objectives of any Town plan or policy; and
2. the Local Board of Health finds that the granting of the variance is necessary for the
reasonable use of the land and is the minimum variance which would alleviate the
specific unnecessary hardship found by the Local Board of Health to affect the
Applicant; and
BE IT FURTHER,
RESOLVED, that the Local Board of Health hereby approves the application of John
Hampshire for a variance from the Sewage Disposal Ordinance to place the already installed 2,000
gallon septic holding tank 31.1f' from the Dream Lake shoreline in lieu of the required 50' setback
on property located at 62 Dream Lake Road in the Town of Queensbury and bearing Tax Map No:
279.17-1-10.
Duly adopted this 27th day of September, 2021,by the following vote:
AYES : Mr. McNulty, Mr. Metivier,Mr. Freer, Mr. Ferone
NOES : None
ABSENT: Mr. Strough