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PT-0522-2022 Property Transfer Sewage Disposal Information Form Date: Town of Queensbury 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.aueensbury.net AVAI _)'r- AV,41 (Name of Owner/Applicant) Re: Onsite Wastewater Treatment System Inspection Information Request for: 3A �� (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 V 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, DECEOVIE AUG 19 2022 John O'Brien, Director BuJding and Code Enforcement TOWN W F QUB CODES Y Town of Queensbury Property Transfer Packet Revised Julv 2022 Office Use Only Permit#: Town efczFensbun• Fee:. $ 2 j 742 Bay Road,Queensbury,NY 12804 P:518-761-8206 or 518-761-8205 Invoice#:530 to www.aueensburv.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: 63 XLV�_ rDoeD O''4 CJ4�z_/11S8OR y Tax map number: 1-2 -1 . /a - / Y Property owner: AAW ol�.9i✓ZZT &/2a'912 s% 41&1/ d Mailing Address(c/s/z): 1925 Cell#: 365- 2,94- -O(ogo Land Line#: 6UA Email: Q„G +0 Y-a/)q 0-6-'Yl p E C E IE Applicant(if different than above): -0 Mailing Address (c/s/z): AUG 19 2022 Cell#: Land Line#: TOWN OF QUEENSBURY Email: BUILDINGS CODES ❑ Proposed Owner ❑ Realtor ❑ Attorney ❑ Other(explain: ) Septic Contractor: Q c3 4191/7--Ei592 VC 4V q i 14q Mailing Address(c/s/z): %• � L LYi _ :7R�AD. �/�/CE �/E©'� E� Cell#:�9-3LeI" -a79YLand Line#: Email: Reason for Inspection Request: ®On the market ❑Future listing ❑Sale Pending ❑ Deed Transfer ❑Other: Property Transfer Packet Revised July 2022 HOUSEHOLD INFORMATION "PLEASE SEE SEPARATE PAGE FOR EXEMPTIONS" #Bedrooms 8 # Bathrooms_,2_ # Kitchens Jacuzzi tubs) o Garbage grinder o Onsite Wastewater Treatment System: How many systems are on the property? l Year system(s) installed: Tanks 2 Size of Septic Tank Type of Absorption System: ae j Jee- �'`d v�ehv� s C/1ji iZe2 r L-n je_C15 - I Are all system components wholly within the property boundaries? ®Yes ❑ No Are system plans available? ® Yes ❑ No Does the system(s) serve multiple properties? ❑ Yes g No If yes, describe Maintenance: Service agreement? ❑ Yes ja No; If yes, business' name Date of last inspection N/A❑ Date tank last pumped Oa N/A ❑ Frequency of pumping N/A❑ —,S-U USe_ Z AO List known repairs/replacements, with dates: �k) ";` P E_-o Date Type // of Repair/Replacement Nd lz.e/ Operation: System problems? ❑ Yes M No Sewage odors? ❑ Yes ® No Direct surface discharge(s)? ❑ Yes No Back-up of toilets? ❑ Yes W No Back-up of any other fixtures? (e.g. slow drains) ❑ Yes Rr, No Seasonal ponding or breakout of leach field? ❑ Yes No Property Transfer Packet Revised July 2022 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 30% of the fee is retained by the Town of Queensbury. Signature of property owner or authorized agent: Affiliation: ®owner ❑agent ❑other: CL}7G �' 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 July 2022 SYSTEM INSTALLATION NOTES WASTEWATER SYSTEM DESIGN «nsrncnbr nub a u wow w Ms w.wxc Nw n.abvb.va wM la xrs Drnanmsr v f li vt ,� avow lames¢e e Door aorta ams KLLM Nuimux wumwo srsmrs.rm.sM ral wsrw.r,w v Mwlwesrs vwe mm wwuoum rirmem w mna eux Ir.v terns L ,�1 � _... °�.� �mine n�-�1 uuveml v Ir.w r sr Imv.osmmw em ro nc Done aaumn.nc avu uw nob° 4 -- 't /v D.e�u�rEvw�sb cw u.x mars) wxE¢beam.w e.°m w DaaR m E¢sM aa.cm.Rus v sm. / � �,� '- I � woes nnv-Ilo wnmeoolr rr.mwlr v m®®rme:vmrEw.rzn vas um ores r.aec wxE¢.s srow..Im e.ec snub •,,. �' t` il, f / see amr.a.-mov ,Y, abea sws ee amnrol aP-ao Des ¢cua®me�nabaw vrna ceum sms.bo ieurt wmaawne:sme xm we t' ` 1�� •4 `o'rmxw io1°�emeoar o. 1v%C0 rxs rve.amen a um er M:a s wzrraa uwcw,9 sn+.urwr cwlxmrs am'nMwr 1; S� ._ / x r-evo cu v¢usr cauarz ws ronPs amubb9 evxrs¢onm wmsuar mmiwrs rmr auu a wo rM xnu Dow 1 r' - 9 / n.m n rmN-row ca P¢Ger bwvcrz w w.c.Eaa •I I vwn Na bswe.E Imm suu BY vxan ro anm e.aw.0.ub besot aro.a nEwbr.wr mo.nc 1 � .rPlca,orr wm.w rzq.e.ab -a urnw.vay.smr sit 1•, - - � -!«o aoJrtn amM %rest us reswecuevarr nMer nm.emn9w wa..rrm rPwn xis®+emwm / `r µ`.. ` wrmra rv.sxarr srem re amvm.ro.wwbltD e.ab Imes Ra wsrxunw¢wwR srrEl.ararrav .NEIGHBORHOOD MAP I ,sr eaanaurz ream ou SfiELOGREPI LOCATION MAP I -- - .""""°'D''0fer-"" rawmrE na wsrwurvl v ru,-mareewe waa mesas m exemrz wrze r�rbiErra re I vbbaE wml suer m¢msmc rNrz ova bsn, caxrn.nr ro me.m.ovu v Ms r.srzwra Mwrmlr arem. -IINNiAIN la'Mno—m w.nNI LOX.Row ua eaa:rao�o.9.a raE.n,,� �.wan ww.a wusr¢avwm mw na wurEwrm w.srzw.rEa mn1,eOio'ONM. amElE SITE SOILS DATA DwMwrDwwa:wE.aaaererzuwbmMroawnrabanxaf.enR. mae I 3Lsrcrr ' I 3J-a/so/la er rou NUTans P.E °mwmwm.mw,b I o-/ -TnaEsr burr SYSTEM MATERIAL SPECTFIGl770N5 xumw•e� ,.ro.b.mo®r,»rmr.wv /-la• -aeD eeaxw sera,rME swo,coeeEEs e: ` "'tea ,r � BWLOEas amE n ro¢.yt m r In'wwm baboon sraE rs-re•-¢Dec •abvv a sa-.o vre eobu nM r/•'vu rmr nwxv aceE NO ORdMB.M,ENDENCE %Hp� m Bf l---OR SW-q PIC neLILL iM r/a•FIR-T iwa/a obi B/a/le BY TOx INTRYNS P.E m ec o-r/r xrc swe-e i fSim �—— `�.—+.—�——— �i9 o-le• -reaavnur twat rwE s,wD mm�m¢ae Dyr rwv-west arwrwr ramae mu¢rrwn rest m cweuwr. A I I 1 la• -TAR¢alwr oa EfDLE ro¢w.vnaw s.wr Taw wTmu xM ero vwr�awrza nlw r 4s ttm®w NO LAdMaW.1RR ENOENCf � - Ty3 y .•Ibm(W IO°A6 Owe Q'IIFr.IBmIRrxN rQib A4E4.g0.WEp Nm!SI/DIAY fiW. e/ene BY TM Nu—Sw Af.. WASTEWATER SYSTEM FILL MATERIAL NOTES x.NO EXL.w1E0 rovml.Pu¢erelry ru Drq Mr dTae.9w a reawm.n(Mnd I A I .bross®v w \ 1 I c o-a• -a.uEur Eabr.LVE swo �,�0vvoi.,w`re a ra• _wa¢aoar Da tea¢ ,.�rzw,�=nm,,�w,M..E•awe¢DN�a,=nm,m=�—Y mw b,—1 raver soirsB I I I�w rwmY ,�bq II _J I o No raourmw.rza EwDD+cr eBobX6wso.rs""oz¢D..�re'''rzlm M:miss a�rrlarz'rs'usrtwa'".r.ar l�mwwr.ww.emmm mar ddd rot I — n I I pp I� , � F � I I N. wsawra snrzw nE wrma s«E¢wsr.um ro vno,mE uwwn v.s-tar¢,rilml eaea.er ^V I G II I I rr--�� nW�Wn�wlr ��.NLa1"�LVG�.W�/SO¢r Mmr ILL w,LPo,I.wALL¢Mbb1D � J`'�,I erve� 'y I� •� §I I /I / Qp4�' � I I a"" ,"� it ama m wsn�uurov awiem'�wnw%¢�ur¢.ur nos, x rr rnn uM mw®mnr�r j'f //T l l � usrxua m xorn mvm v vevosm mwv v mm ru wmu rroa ro reumaum m 0 ' q WASTEWATER SYSTEM PLAN sr r'-ab' 7AX MAP#227.38-3-02 • nb 00bbM btDf w E Ym4D Iw®.NL IM ms l,.w 4w. _ - -- -- - 0 ISSUEO TOR SFPnC P T Y/II/l6 2�22 No. Revfs/ons Dote 42 PT-0522 WASTEWATER SYSTEM PLAN .18-1- DI �&dol. MAP REFERENCE: An K.S63 Ha wt Wwcd T ust ® I 22 e..u a r .aav.REw v.a of Bl Navreratl Rostl New Rork ndt Ann µ a�¢ �%a=E m WASTEWATER SY57EM SETBACK SCHEDULE roan DrtTuaaxmary,WenBrl rounry,M' Cti�r��� x.elM TEE K ME M'N dw°e M 4eM xD1[n Wfe e e b y.w_b.ryy.. S ora I x 9ibeAVOT FE�.BI£MUST,'SMAiED IM Ow WaN9ab9Y, W.IR¢N ID9 xOMOnw Robe Hanneford aaw x Mnr�a Pa�.�e ar nt a°�,�n Nr laeo, fob n�e;.a�eL;s 63 Rd market �MS n.rzD � Lsle)r.s-n w foe. 29945 01-Si aao>� Hutchlna EnOtnbDHnp sl9 r.s-Dsca r. property Transfer -- on the