PT-0536-2022 1
Property Transfer Sewage Disposal Information Form
�.
�% Date:
Town of Queensbury
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.gueensbury.net
w (Name of Owner/Applicant)
Re: Onsite Wastewater Treatment System Inspection Information Request for:
(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 bestjob 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 111 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,
AUG 2 9 2022
John O'Brien, Director TOWN OF QUBEN4BURY
BuJding and Code Enforcement BUILDING&COD I
Town of Queensbury
Property Transfer Packet Revised July 2022
Office Use Only
Permit#: ` 053�•�Z2
TOU77 of(-w ns aq Fee:
742 Bay Road,Queensbury,NY 12804 2 c�
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:
Tax map number: \1 I _1
Property owner:�''.NVCLM � l-k'4 AJAW 1'n
Mailing Address (c/s/z): We
Cell#7j;% �0 ' LILfC)y Land Line#: Sg5 'q 'y.�y554
Email: �Mcyt�'tk•��'• �te� �, �
Applicant (if different than above):
Mailing Address (c/s/z):
Cell#: Land Line#:
Email: r� Q
❑ Proposed Owner ❑ Realtor ❑ Attorney ❑ Other(explain:
�,.. T®vim
Septic Contractor:V ognxi\'t.,���Cl �+Ul,�� Q UR�o,�����
Mailing Address (c/s/z);
Cell#: Land Line#:sl `�" �o�?J ` �t{rj
Email:
Reason for Inspection Request: , cc
❑On the market ❑Future listing ❑Sale Pending Deed Transfer El Other: e-
Property Transfer Packet Revised July 2022
HOUSEHOLD INFORMATION
"PLEASE SEE SEPARATE PAGE FOR EXEMPTIONS"
# Bedrooms `"� # Bathrooms 1 # Kitchens Jacuzzi tub(s) Garbage grinder
Onsite Wastewater Treatment System:
How many systems are on the property?
Year system(s) installed: Tank4!�LU Size of Septic-TankQ
Type of Absorption System�� We VLjtxV tk, ` 14-rbc� °` ov<XPVt
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 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. [k No
Back-up of any other fixtures? (e.g. slow drains) ❑ Yes E� 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: M owner ❑agent ❑other:
Please print name: V���,�,c,amWi ct C l mil( E r1
Signature: �y C Date:'Ivc"�q' %MZ
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
TOWN OF QUEENSBURY
742 Bay Road,Queensbuty,NY 12804-5902 (518)761-8201
Community Development -Building & Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: P20120413 Date Issued: Tuesday, May 21, 20113
This is to certify that work requested to be done as shown by Permit Number P20120413
has been completed.
Tax Map Number: 523400-239-019-0001-006-000-0000
Location: 24 JOSHUA ROCK Rd
Owner: WILLIAM & CHERYL BALDWIN
Applicant: WILLIAM & CHERYL BALDWIN
This structure may be occupied as a:
Septic Alteration Residential
Test Pit/Pere Test Review By Order of Town BoardTOWN OF QUEENSBURY
Issuance of this Certificate of Compliance DOES NOT relieve the C 1)
owner of the responsibility for compliance i `*' 4;4 44t
property p ty p with Site Plan,
Variance,or other issues and conditions as a result of approvals by the Director of Building&Code Enforcement
Planning Board or Zoning Board of Appeals.
TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building&Codes (518)761-8256
BUILDING PERMIT
Permit Number: P20120413 Application Number: A20120413
Tax Map No: 523400-239-019-0001-006-000-0000
Permission is hereby granted to: WILLIAM& CHERYL BALDWIN
For property located at: 24 JOSHUA ROCK Rd
in the Town of Queensbury,to construct or place
at the above location in accordance with application together with plot plans and other information hereto filed
and approved and in compliance with the NYS Uniform Building Codes and the Queensbury Zoning
Ordinance. Type of Construction Value
Owner Address: WILLIAM&CHERYL BALDWIN Septic Alteration Residential
7728 DRYER Rd Test Pit/Perc Test Review
VICTOR,NY 14564-0000 Total value
Contractor or Builder's Name/Address Electrical Inspection Agency
CRANDALL EXCAVATING
793-0431
63 WOODCHUCK HILL Rd
LAKE GEORGE NY 12845-0000
Plans&Specifications
2012-413
Perc Test/Res. Septic Alteration
$240.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Thursday,August 22,2013
(If a longer period is required,an application for an extension must be made to the code Enforcement Officer
of the Town of Queensbury before the expiration date.)
Dated at the Town of Queensbury; Wednesday,August 22,2012
SIGNED BY for the Town of Queensbury.
Director of Building&Code Enforcement
r
Community Development Office it
Town of Queensbury ■ 742 Bay Road • Queensbury, New York •12804 ' I� OCT 22 2012 'tJ
Office Use Only
c� � f •. r_r''LL.a
TAX MAP NO --I--tv PERMIT NO. C-- PERMIT FEE-9�C� -
APPROVALS: ZONING- TOWN CLERK
APPLICATION FOR SEPTIC DISPOSAL SYSTEM PERMIT: A PERMIT MUST BE OBTAINED
BEFORE WORK BEGINS.APPLICATION IS SUBJECT TO REVIEW BEFORE ISSUANCE OF A VALID PERMIT.
`
OWNER A1 t t..t_tArA Y:)AQ1 I kAN 11104 INSTALLER: GR�41►1�+�4LL.. y6��"1 NC.
ADDRESS: �T`7r ZS i JL�'t'E-�P+ 1 A-� ADDRESS. G=—J C_t+%tC w 4 An-L_� LG. tVY
PHONE NOS v 1 C"Td ` NY PHONE NOS.
LOCATION OF INSTALLATION:
RESIDENCE INFORMATION:
YEAR BUILT NO.OF X COMPUTATION = TOTAL DAILY FLOW
BEDROOMS Gallons per bedroom GARBAGE GRINDER
1980 or older X 150 = INSTALLEDQ
1981-1991 X 130 = SPA OR HOT TUB
1992-present X 110 INSTALLED?
PARCEL INFORMATION:
✓ TOPOGRAPHY: FLAT ROLLING 1✓STEEP SLOPE %SLOPE 5-10
✓ SOIL NATURE: SAND LOAM— CLAY OTHER
✓ GROUNDWATER AT WHAT DEPTH? > f
✓ BEDROCKlIMPERVIOUS MATERIAL. AT WHAT DEPTHS
A}o"t
✓ DOMESTIC WATER SUPLY: MUNICIPAL WELL V (If well.water supply from any septic system absorption is: -7 5 ftl
✓ PERCOLATION TEST. RATE IS 1±1^19 PER MIINUTE PER INCH[mp7 (Pest to be completed by a licensed professional
engineer or architect) I " -:7
PROPOSED SYSTEM FOR NEW CONSTRUCTION All individua sewage dispotisal systems must be designed by a licensed professional engineer or
architect(unless installed in a Planning Board approved subdivision).
TANK SIZE: Z1 tOGALLON(MIN.SIZE IS 1,000 GAL.)Add 250 gallons to the size of the septic tank for each garbage grinder,
spa or whirlpool tub.
SYSTEM TYPE:
❑ABSORPTION FIELD(WITH NO.2 STONE) Total length ft. Each trench X
❑SEEPAGE PIT(S)(WITH NO.3 STONE) How many? Size?
%ALTERNATIVE SYSTEM Bed or other type? F_j_,aEr1 (SOF:5E:1 C��IFtG.��ArTi �t1 — oZ�
❑ HOLDING TANK SYSTEM Total required capacity? Tank size? Number of tanks?
NOTE: ALARM SYSTEM AND ASSOCIATED ELECTRICAL WORK MUST BE INSPECTED BY A TOWN APPROVED ELECTRICAL
INSPECTION AGENCY. PLEASE REVIEW LIST PROVIDED.
For your protection,please note that pursuant to Section 136-29 of the Code of the Town of Queensbury,any permit or approval
granted which is based upon or is granted in reliance upon any material misrepresentation or failure to make a material fact or
circumstance known by or on behalf of an applicant,shall be void.
have read the regulations with respect to this application and agree to
abide by these and all requirements of the Town of Queensbury QUESTIONS? CALL 761-8256 OR EMAIL
Sanitary Sewage Disposal Ordinae. ,^ codes(o�aueensbury.net
� � —�� VISIT OUR WEBSITE FOR MORE INFORMATION
CSlep ature of Person Responsible Date www.aueensbury.net
Town of ueensbur Building&Codes Enforcement ■7 , - �..Q y g t Oft ce 42 Bay Road Queensb ,NY t2804
DEEP HOLE PE �'l ! �
/ RC TEST QG 2
3 Request for Town Engineer Review_ 2 2p�?
P 3
Property Owner. 1-P4 Phone:
Property Owner's `•-�
Address:
Location of Test:
'Applicant's Engineer: Phone:
Applicant's Agent: Phone: ���—b�t7
Additional Notes:
4.Reason for Request? New Septic System Replacement Septic System Failed Septic System
Subdivision ❑ Site Plan Review
2.Are Wetlands present? YES NO UNKNOWN
Note: APRlicant is r uired to en a e an engineer for design and testing of the system. The Town
Engineer's resnonsibility is to witness system testing only.
PLOT PLAN: Plot plan, to scale, to be submitted with application
FEE SCH
a. $200 Flat Fee Date Paid: $ dal
Check No.:
b. OR Fee to be determined during To Be Determined:
Site Plan/Subdivision review process
SIGNATURE:
In carrying out the provisions of Article IV, the Local Board of Health or the enforcement officer may
engage the services of a qualified professional consultant for expert review and recommendation arising
from the carrying out of the provisions of Art. IV, including but not limited to the review of plans,
specifications and reports, attendance at inspections, dye tests, deep hole test pits, septic related deep
hole and percolation tests, system installations, and any other aspect of any matter contained in this Art.
IV, and any costs incurred in such review shall be paid to the Town by the owner of the property before
any approval can be granted under this Art. IV shall become effective within 30 days of presentment of an
invoice for same,whichever is sooner. Such costs shall not exceed $1,500 without prior written notice to
the party to be charged with same.
My signature below indicates I have thoroughly read and understand the instructions, agree to the
submission requirements and have completed the application. I also fully understand that additional
engineering fees may be necessary per Town of Queensbury Local Law 136-14D.
SIGNATURE OF APPLICANT: Date:
SIGNATURE OF AGENT: [ Date: l-Z
Original (B&C File) Canary(Planning) Pink(Applicant) Gold(Town Clerk)
Septic Inspecction Report
Office No. (518)761-8256 Date Inspection request received:
Queensbury Building&Code Enforcement Arrive: am/pm rt: ` am/pm
742 Bay Rd.,Queensbury, NY 12804 Inspector's Initials:
NAME: PERMIT NO.: Z. �. Q
LOCATION: 11) �'ti _ INSPECT ON:
RECHECK:
Comments and/or diagram.
Soli Type: Sand Loam I Clay
lype of Water: Munici 1 Well Water
Waterline separation distance ft.
Well separation distance ft
Other wells: ft.
Well Casing Length 5V+/- Y N N/A
150'to well required if NO
Absorption Field. Total lenqLhft•
Length of each trench ft.
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
Opening Seated: _Y N
End Cap N
Inl Outlet Pipes&Baffles Y N
Manholes I.2"or less below grade Y_..N
[provide extension collar If Yes Y N
Location rations
Foundation to tank fL
Foundation to absorption ft.
Separation of Pits A N fL
Conforms as per Plot Plan Y. N
Engineer Report and As-Built V Y N
ETU Maintenance Contract _.__ ._N
provided
Location of System on Property:
Front R r ' Left Side Right Side Middle Front Middle Rear
stem U S s•
pro
Pa I Approved and needs to be re-inspected,please call the Building&Codes Office
Disapproved
L:1Pam Whiting\2010wa ing Codes Fonns\lnspecdan FormsVqep0c Inspection Report`03 2910.doc
Septic Inspection Report
Office No. (518)761-8256 Date Inspection request received:
Queensbury Building &Code Enforcement Arrive: amJ m De rt! " am/pm
742 Bay Rd.,Queensbury, NY 128D4 Inspector's Initia .
NAME: QaA to tn PERMIT No .
LOCATION: AA INSPECT ON:
RECHECK:
Comments and/or diagram
Soil T : Sand Loam Clay
-MW of Water: Municipal Well Water
Waterline separation distance ft.
Well separation distance ft.
Other weals:
Well Casing Length 50'+/ - Y N N/A
150'to well uired if NO
Absorption Field: Total lengthft.
Length of each trench ft.
Depth of trenches ft.
Size of Stone
Seepage Pits: Number
Size., x
Stone Size:
Pi in Size Tpe
Buildingto tank cp �l
Tank Distribution Box
Distribution
Box to Field I Pit
Opening Sealed: Y_N r
End Ca Y N
Inlet/Outlet Pipes&Baffles Y N
Manholes 12'or less below grade Y_N
(provide extension collar if Yes Y N
Location Separations
Foundation to tank ft.
Foundation to absorption ft.
Separation of Pits ft
Conforms as per Plot Plan Y N
Engineer Report and As-Built _Y JL N
ETU Maintenance Contract Y_N
provided
Location of System on Property:
Front Rear Left Si Right Side Middle Front Middle Rear
System Use Sta s:
ParMti
ppro
Approved and needs to be re-inspected, please call the Building&Codes Office
Disapproved
LAPam Whiting\2010\Building Codes Fonns\Inspection Forms\Sepdc inspection ReporL03 2910.doc
Septic Inspection Report
Office No. (518)761-8256 Date Ins on req
Queensbury Building&Code Enforcement Arrive: a p rt: �amA9 --
742 Bay Rd.,Queensbury, NY 12804 Inspector's Initials:
NAME: RMIT NO.: <4 1 3
LOCATION: f INSPECT ON:
RECHECK:
Qgmments and/or diagram
Soil T San m Clay
Type of Water: Mu I Well Water
Waterline separation distance ft.
Well separation distance fL
Other wells: ft.
Well Casing Length 50'+/- Y N N/A
150'to well required if NO
Absorption Field: Total length ft.
LenqLh of each trench ft.
Depth of trenches ft.
Size of Stone
Seepage Pits: Number
Size: x
Stone Size:
Piping Size Type1
Building to tank
Tank to Distribution Box
Distribution Box to Field Pit
nin Sealed: _Y N
End Cap N
Inl Ojn&Baffles Y
Manholes 12 r less below grade Y_ p
rovide extension collar if Yes Y N
Location I Separations
Foundation to tank ft.
Foundation to abso ion ft.—
Separation of Pits ft.
W'Conforms; r Plot Plan I _Y
eer e - 110, Y N
ETO-Winteriance Con act Y N
provided
— —
Location of System on Property:
Front R Left S Right Side Middle Front Middle Rear
System Use Sta :
Approved
Partial Approved and needs to be re-inspected, please call the Building&Codes Office
Disapproved
L:\Pam Whit1M\2010\8W1d1ng Codes Farmsunspection For sifttic Inspection Repots-03 2910.doc
Septic Inspection Report
Office No.(518)761-8256 Date Inspection request received:
Queensbury Building&Code Enforcement Arrive: am/ m Depart: am/pm
742 Bay Rd.,Queensbury, NAY 12804 Inspector's Initials-
NAME: W b tW ; p PERMIT NO.:
LOCATION: 0. INSPECT ON: /3
RECHECK:
Comments andlor diagram
Soil T Loam Clay
Type of Water: Municipal Well Water
Waterline separation distance ft.
Well separation distance fL
Other wells: ft.
Well Casing Length 50'f/- Y N N/A
150'to well Muired if NO
Absorption Field: Total lengthft.
Length of each trench ft.
Depth of trenches I ft.
Size of Stone
Seepage Pits: Number
Size: x
Stone Size:
Pi in Size Type
Buildingto tank C
Tank to Distribution Box
Distribution Box to Field Pit
Opening Sealed: _ N 7 End Ca
Inlet/Outlet Pipes&Baffles Y N
Manholes 12"or less below grade L .� " -
rovide extension collar if Yes Y WN
Location Separations
Foundation to tank ft.
Foundation to absorption ft.
Separation of Pits ft.
Conforms as per Plot Plan _Y—N
Engineer Report and As-Built Y N � C
ETU Maintenance Contract Y N
provided Qc
Location of System on Property:
Front Rear Left Side Right Side Middle Front Middle Rear
System Use Sta
A
Pa al AnnM=Nnd needs to be re-inspected, please call the Building&Codes Office
Disapproved
L:\Pam Wh1ting\2010\8uiidfig Codes won FormsXfttic Inspection Repor1_03 29 10.doc
RESOLUTION APPROVING WILLIAM BALDWIN'S APPLICATION FOR
SANITARY SEWAGE DISPOSAL VARIANCES
RESOLUTION NO.: BOH 27,2012
INTRODUCED BY: Mr.John Strough
WHO MOVED ITS ADOPTION
SECONDED BY: Mr.AnthonyMetivier RF COPY
WHEREAS, William Baldwin filed an application for variances from provisions of the
Town of Queensbury On-Site Sewage Disposal Ordinance,Chapter 136 to install a new absorption
field:
1. 72' from Lake George instead of the required 100' setback;
2. 73'.from the well instead of the required 100' setback;
3. 3' from the property line instead of the required 10' setback;and
4. 12' from the dwelling instead of the required 20' setback;
on property located at 24 Joshua Rock 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 conducted a public hearing concerning the
variance requests on Monday,October 15`h,2012,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 variances, the Local Board of Health determines that the
variances 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 variances is necessary for the
reasonable use of the Iand and is the minimum variances 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 William
Baldwin for variances from the Sewage Disposal Ordinance to install a new absorption field:
1. 72'from Lake George instead of the required 100' setback;
2. 73' from the well instead of the required 100' setback;
3. 3' from the property Iine instead of the required 10' setback;and
4. 12' from the dwelling instead of the required 20' setback;
on property located at 24 Joshua Rock Road in the Town of Queensbury and bearing Tax Map No.:
239.19-1-6, contingent upon the applicant digging up and removing the old tank, with such
construction to be completed by June 1".2013.
Duly adopted this 15''day of October,2012,by the following vote:
AYES: Mr.Montesi,Mr. Strough,Mr.Brewer,Mr. Stec,Mr.Metivier
NOES: None
ABSENT: None
2
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