PT-0049-2022 Property Transfer Sewage Disposal Information Form
Town of Queensbury Date: Z !O Z"�-
742 Bay Road,Queensbury,NY 12804 D E C E
P:518-761-82S6 www.aueensbury.net
FEB 1 12022 E01
d✓�CLiA/J We��G'�i3G G�
(Name of Owner/Applicant) TOWN OF QUEENSBURY
BUILDING&CODES
Re: Onsite Wastewater Treatment System Inspection Information Request for:
/��s%c./iliyi✓�Zo�J, �vc.�.�lSddjLy
(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 aboutthe 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$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 11" of the current, or following year (whichever comes first), a map locating the septic
system and payment totaling$2275($2000 refundable deposit plus$275 permit fee). The deposit is forfeited
if the owner fails to complete the repairs or installation as stated above.
If you have any questions, please call'.
Phone: (518)761-8256 Email: kated@queensbury.net
Thank you.
Sincerely,
4
David Hatin, Director
Building and Code Enforcement
Town of Queensbury
Property Transfer Packet Revised April 2021
HOUSEHOLD INFORMATION.
*"PLEASE SEE SEPARATE PAGE FOR EXEMPTIONS"*
. # Bedrooms Z # Bathrooms Z # Kitchens Jacuzzi tub(s) Garbage grinder
Onsite Wastewater Treatment System:
How many systems are on the property? /
Year system(s) installed: Tank 1996 Size of Septic Tank ioOD-CIIZ-
Type of Absorption System: 44-:aca C/ccZ
Are all system components wholly within the property boundaries? Eyes ❑ No
Are system plans available? ❑ Yes ❑ No p111476r✓`IL AL. ,i4r u/6;-IZAr Zc-a-t//,C6 b �3y
Does the system.(s) serve multiple properties? ❑ Yes [j�'No
If yes, describe
Maintenance:
Service agreement?Q Yes E No; If yes, business' name
Date of last inspection poi, 417 N/A❑ Date tank last pumped ioi� za17 N/A❑
Frequency of pumping 5-Yayxs N/A ❑
List known repairs/replacements,with dates:
2ti5
Date Type.of Repair/Replacement
Operation:
System problems? ❑Yes F/ No
Sewage odors? ❑ Yes No
Direct surface discharge(s)? ❑ Yes [✓]�No
Back-up of toilets? ❑Yes [j No
Back-up of any other fixtures? (e.g. slow drains) ❑Yes FN
ro
Seasonal ponding or breakout of leach field? El Yes 0
Property Transfer Packet Revised April 2021
DI� C E �n E Office Use Only
L� V Permit#: P►�
Fot►n o£.Qirrcns8urp FED 1 1 2022 Fee:_$ 2 Z7 S
742 Bay Road,Queensbury,NY 12804 TOWN OF QUEENSBURY Invoice#:
P:518-761-8206 or 518-761-8205 BUILDING& CODES
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: /rIl �.r/
Tax map number: 2.Z �. /7 '�- 9•Z
Property owner: .(�c��r�i
Mailing Address(c/s/z): /V'y
Cell#:S"��7Yy-/g�� Land Line#:
Email:/?/7 @J/ZoAV/2 tAIAIC�1r...C anf
Applicant(if different than above):
Mailing Address(c/s/z):
Cell#: Land Line#:
Email:
❑ Proposed'Owner ❑ Realtor ❑ Attorney ❑ Other(explain: )
Septic Contractor:
Mailing Address(c/s/z):
Cell#: Land Line#:
Email:
Reason for Inspection Request:
❑On the market ❑Future listing ❑Sale Pending dDeed Transfer ❑Other:
Property Transfer Packet Revised April 2021
Statement of Acceptance of Conditions:
I agree to:
e 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;
e Have a seetage hauler on site (to pump the tank after*the inspector verifies flow
from fixtures);
➢ Tank must be pumped in presence of inspector
e Have an authorized representative present at the site;
e 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: (downer ❑agent ❑other:
Please print name: All(-(-M ►, Ale-:7106,49a-d
Signature: /,� l/. Date: ezL
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
EXEMPTION CONDITION OPTIONS
Due to one of the conditions listed below,I am requesting an exemption from the
Septic Inspection Upon Property Transfer by the Town of Queensbury:
PLEASE CHOOSE ONLY ONE CONDITION BELOW IF YOU ARE REQUESTING A WAIVER
❑ The property to be sold or transferred will-not be inhabited,and the new owner plans to demolish the
existing structure. In order to qualify for the exemption,a notarized affidavit must be submitted to the
Building and Codes Enforcement Office stating that the dwelling will not be inhabited and that it will be
demolished with no immediate plans to rebuild or the dwelling will not be inhabited,it will be
demolished and rebuilt,in which case the affidavit shall be accompanied by a site plan,including
adequate detail to demonstrate a lawful OWTS,together with a check payable to the Town of
Queensbury in the amount of$2,000.Such funds will be held in a non-interest-bearing escrow account
and will be released, in the former case,upon issuance of a demolition permit and,in the latter case,
upon issuance of a certificate of compliance from the Building and Codes Enforcement Office. If the
Property Transfer inspection is not completed within that 6 (six) month timeframe,
the $2000 will be forfeited.
An OWTS inspection was not able to be completed prior to the conveyance of real property due to
inclement weather.In order to qualify for the exemption,a notarized affidavit from the new property
owner to complete the requisite OWTS inspection within six months of the date of the conveyance of
real property, or June 1,whichever comes first,must be filed with the Building and Codes Enforcement
Office.A check payable to the Town of Queensbury in the amount of$2,000 will be held in a non-
interest-bearing escrow account and shall be released upon the completion of a satisfactory OWTS
inspection from the Building and Codes Enforcement Office.If the Property Transfer
inspection is not completed within that 6 (six) month or June 111 timeframe, the
$2000 will be forfeited.
❑ The property to be sold or transferred contains an existing OWTS that does not comply with the
provisions of this article,,and the prospective purchasers and/or the Seller wish to forgo an inspection
in favor of installing an approved OWTS within six months of the transfer of property. In order to
qualify for the exemption,a notarized affidavit must be submitted to the Building and Codes
Enforcement Office stating that the existing OWTS will be replaced within six months from transfer of
property.The affidavit must be accompanied by a site plan,including adequate detail to demonstrate
that the replacement OWTS will comply with this article,together with a check payable to the Town of
Queensbury in the amount of$2,000. Such funds will be held in a non-interest-bearing escrow account
and will be released upon issuance of a certificate of compliance from the Building and Codes
Enforcement Office.If the Property Transfer inspection is not completed within that 6
(six) month timeframe,the$2000 will be forfeited.
Property Transfer Packet Revised April 2021
❑ During the OWTS inspection,a failure of the septic system was determined_Due to winter and
frozen conditions,the repair to an existing OWTS could not occur or a new OWTS could not be
installed before the conveyance of real property.In order to qualify for the exemption,a notarized
affidavit from the new property owner to complete the installation or repair of the septic system within
six months from the date of the conveyance of real property,or June 1,whichever comes first,must be
filed with the Building and Codes Enforcement Office.A check payable to the Town of Queensbury in
the amount of$2,000 will be held in a non-interest-bearing escrow account and shall be released upon
the completion of the repair or installation of a new septic system and a satisfactory OWTS inspection
from the Building and Codes Enforcement Office. If the Property Transfer inspection is not
completed within that 6 (six) month or June 1'timeframe, the $2000 will be
forfeited.
❑ There is a record of a septic system inspection upon property transfer permit and inspection completed
and passed within the last three years_ Please provide a copy of this record.
PLEASE READ NOTICE THOROUGHLY:
Failure to complete the inspection, obtain the permit or complete all repairs/installations
identified in the preceding subsections of this section within the time provided or any subsequent
deadline established by the Building and Codes Enforcement Office will result in forfeiture of the
moneys held in escrow, and the Town may use such funds toward abating the conditions caused
by each such violation of this article.
Inspections must take place within one (1) year of submission of a completed application.
Inspections scheduled to take place after the one year period will be subject to submission
of a renewal application and payment of the renewal fee based on the current fee schedule.
***ONLY SIGN THIS PAGE IF YOU ARE OPTING FOR A WAIVER REQUEST!!***
I have read and understand the above notice regarding the expectations and possible forfeiture
of moneys submitted to the Town of Queensbury for an exemption request.
Seller: /
Print Name: c"i?A 'er�ye Lc�
Sign Name: Alm "Or Date: 1, zz
Buyer:
Print Name:
Sign Name: Date: io/zz.
Property Transfer Packet Revised April 2021
"Stormwater management on each lot shall conform to the approved subdivision
" Stormwater Management Plan which is comprised of, the following documents pre-
1.1. Thomas Jarrett, P.E.:
1. Stormwater Management Report, Beeman Subdivision. March 1996
2. April S. 1996 letter addressed to William Levandowski. Rist-Trost, Assoc:
i P.C-
3. April 22. 1996 letter addressed to James Martin, Community Developmen
of Queensbury (note that the third paragraph should read "review by the. T,.
f Queensbury Planning Board")"
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_ 227.17-1-9.2 PT-0049-2022 _ -
DE EOV3 f o William Wetherbee
18 Hillman Road
FtB 1 1 .2022 Property Transfer
TOWN OF QUEENSBURY
BUILDING&CODES
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Director Building and Code Enforcement February 10, 2022
Town of Queensbury
I am requesting a 6-month exemption from the Septic Inspection due to inclement weather. I
agree to have the septic system,located at 18 Hillman Road, Queensbury NY 12804,inspected
prior to the compliance date of July 19, 2022 as noted in the Violation Letter sent to me on
January 19, 2022.
William A. Wetherbee
518-744-1917
1917@roadrunner.com
Izz'e—, OO'-3;P'
MARIA A.GAGLIARDI
Notary PUMC, state of Ncm York
No..01 GA6061460
Qualified in Warren County
Commission Expirps'July'i6,_ 2
DES E 0 V E
MAR 2 5 20,21
2'1)
TOWN OF QUEENSBURY BUILDING&CODES
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