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PT-0531-2022 Property Transfer Sewage Disposal Information Form Town of Qeensbury Date: 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.gueensbury.net '8 re,/IA, (Name of Owner/Applicant) Re: Onsite Wastewater Treatment System Inspection Information Request for: "3 e a A (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 (seethe 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 Queensbu ry'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 1st 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, A John O'Brien, Director Buifding and Code Enforcement Town of Queensbury Property Transfer Packet Revised July 2022 Office Use Only Permit#: ?'05Z-A 2b22- "Ors ur}' Fee: - 742 Bay Road,Queensbury,NY 12804 P:518-761-8206 or 518-761-8205 Invoice#: 5?JZ( www.gueensburV.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: 5-Z L Q- (�`�9 — 82 I--d00l — ©2.p Property owner: �� y' c7 Q ,lJL YbL6L�r'L Mailing Address(c/s/z): �5� a Cell#: Land Line#: Email: �vP Qma-d V Applicant(if different than above): UU Mailing Address (c/s/z): AUG 2 4 2022 611#: Land Line#: TOWN OF QUS NSBURy BUILDING&CODES Email: ❑Proposed Owner ❑ Realtor ❑ Attorney ❑ Other(explain: ) Septic Contractor: D�1L- Mailing Address (c/s/z): Cell#: Land 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__I_# Bathrooms a # Kitchens_L Jacuzzi tub(s) Garbage grinder Onsite Wastewater Treatment System: How many systems are on the property? Year system(s) installed: Tank d-013 Size of Septic Tank 192J Type of Absorption System: Are all system components wholly within the property boundaries? Vyes ❑ No Are system plans available? EyYes ❑ No Does the system(s) serve multiple properties? ❑ Yes [Q/No If yes, describe Maintenance: Service agreement? ❑ Yes EdNo; If yes, business' name Date of last inspection N/A❑ Date tank last pumped 6 R1 N/A❑ Frequency of pumping N/A❑ List known repairs/replacements,with dates: Date Type of Repair/Replacement Operation: System problems? ❑ Yes [2No • Sewage odors? ❑ Yes [ r No • Direct surface discharge(s)? ❑ Yes EYNo • Back-up of toilets? ❑ Yes U No • Back-up of any other fixtures? (e.g. slow drains) ❑ Yes EyNo • 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/car 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: Please print na e: 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 nLr� .►7 �, . .'1 Community Development Office �l�kl AUG 15 201 t► z Town of Queensbury - 742 Bay Road - Queensbury, New York'612804. � lUevIJC- Office Use ON ""'''" %�iL y I TAX MAP NO. `f '4�t,O PERMIT NO. "• 6�/ PERMIT FEE—J�--f— 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: DOROTHY HUNT INSTALLER: ELLSWORTH & SON EXCAVATING ADDRESS: 34 REARDON ROAD ADDRESS:`' ELLSWORTH LANE, LAKE GEORGE NY 12845 PHONE NOS. PHONE NOS.P: (518) 792-9246 F: 018) 792-4242 LOCATION OF INSTALLATION: 34 REARDON ROAD RESIDENCE INFORMATION: YEAR BUILT NO.OF x COMPUTATION = TOTAL DAILY FLOW BEDROOMS Gallons per bedroom GARBAGE GRINDER 1980orolder X 150 = INSTALLED? NO 1981 -1991 X 130 = SPA OR HOT TUB 1992-present 3 X 110 = 330 INSTALLED? No PARCEL INFORMATION: ✓ TOPOGRAPHY: FLAT ROLLING STEEP SLOPE %SLOPE ✓ SOIL NATURE: SAND / LOAM CLAY OTHER ✓ GROUNDWATER: AT WHAT DEPTH? >52" ✓ BEDROCKIIMPERVIOUS MATERIAL: AT WHAT DEPTH? >52° ✓ DOMESTIC WATER SUPLY: MUNICIPAL WELL (If well:water supply from any septic system absorption is: 100 g) ✓ PERCOLATION TEST: RATE IS 4 PER MIINUTE PER INCH(mpi) (Test lobe completed by a licensed professional engineer or architect) PROPOSED SYSTEM FOR NEW CONSTRUCTION. All individual sewage disposal systems must be designed by a licensed professional engineer or architect(unless installed in a Planning Board approved subdivision). TANK SIZE: 1,000 GALLON(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? dALTERNATIVE SYSTEM Bed or other type? INFILTRATOR CHAMBERS, 3 LATERALS AT 36' LONG ❑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. I h rea the regula' with respect to this application and agree to a d by se d all q irements of the Town of Queensbury QUESTIONS 7 CALL 761-8256 OR EMAIL S a wag Ordinance. codes@aueensburv.net Signa e t Person Responsible *Dat VISIT OUR WEBSITE FOR MORE INFORMATION j� www.gueensburv.net As &b-M f W� Septic Inspection Report Office No. (518)761-8256 Date Inspection ed: Queensbury Building &Code Enforcement Arrive: part: am/pm 742 Bay Rd., Queensbury, NY 12804 Inspector's Initia s: t NAME: b r Li_A�- IT NO.: LOCATION: I ECT ON: RECHECK: Comments and/or diagram Soil Type: Sand Loam Clay T of Water: Municipal Well Water 7 Waterline separation distance ft. b'����3 Well separation distance ft. Other wells: ft. Well Casing Length SO'+/- Y N N/A 150'to well mulred If NO Abso on Field: Total length ft. Length of each trench ft Depth of trenches ft. Size of Stone SeepNe Pits: Number Size: x Stone Size: Piping Size impq Building to tank Tank to Distribution Box Distribution Box to Field Pit Opening Sealed: Y_N End Cap N Inlet/Outlet P!pes&Baffles _Y N Manholes 12"or less below grade �Y _N —[provide extension collar if Yes Y_N BUM Location Separations Foundation to tank ft. Foundation to absorption fL Separation of Pits ft. Conforms as per Plot Plan N Engineer Report and As-Built Y N ETU Maintenance Contract Y N provided . — — Location of System on Property: Front R Left Side Right Side Middle Front Middle Rear stem Use Sta s: Approved Partial Approved and needs to be re-inspected, please call the Building &Codes Office Disapproved L:\Pam WhIft\2010\13uilding Codes FonmQnspeWon Fmw\$eptic Inspection ReporLO3 29 10.doc Septic Inspection Report am Office No.(518)761-8256 Date Ins n re g l3 Queensbury Building&Code Enforcement Arrive: a rt: Dt a m 742 Bay Rd., ueensbury, NY 12804 Inspector's Initials: NAME: U D NO.: � a LOCATION: 34 yrw gdendAr. INSPECT ON: l 3 RECHECK: Comments and/or diagram Soil Type: Sand Loam Clay Type of Water: Municipal Well Water Waterline separation distance Well separation distance iQQ fL Other wells: I DQ ft. d 1� Well Casing Length 50'+/- Y N N/A 150'to well required If NO Absorption Field: Total lengthft. Length of each trench fL Dept of trenches ft. Size of Stone Seepage Pits: Number Size: x Stone Size: Piping Size Type Building to tank G Tank to ' LAW Distribution O -6oyi- Distribution Box to Field Pit L('t Opening Sealed: N End Ca Y In Outlet Pipes&Baffles N Manholes 12"or less below grade _N [provide extension collar if Yes Y N Location Se rations --T RO O PO MV 4cvv T ' kuw-o' vl` b-VV_+ A Foundation to tank ft. Foundation to abso 'gn o ft.'r — � �1 ��L ���-j-�1C�L ���i�C�►�� Se ration of Pits ft. jF Conforms as per Plot Plan Y E fneer Report and As-Built Y N 1� ETU Maintenance Contract _Y_NV �"T1C 4l . provided t Ek-0 P EVID RT Location of System on Property: IF tl)& a t'�UTC 1� Front Rear Left Side Right Side Middle Front Middle Rear %gtem Use Status: Approved Partial Approved and needs to be re-Inspected, please call the Building&Codes Office Disapproved LAP=Whitfng\2010\BW1ding Codes Foams\ on Foms\SepUc Inspedlon ReporLO3 2910.doc weA PIA�M Septic Inspection Report Office No. (518)761-8256 Date Ins on request received: Queensbury Building&Code Enforcement Arrive:��am/jEDDe part: a pm 742 Bay Rd.,Queensbury, NY 12804 Inspector's Initials: NAME: +4 u .Au PERMIT NO.: LOCATION: 2 INSPECT ON: 0.13 RECHECK: PComments and/or diagram Soil T Qp Type of Water: Municipal e11 Wa 'LtJ�-bQ•1) Waterline se ratio nce ft. Well separation distance 1 Do ft. Other wells• ft. Well Casing Length 50' +/- Y N N/A 150'to well required if NO Abso lion Field: Total fen ft. Length of each trench ft. Depth of trenches 7, 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 Sealed: _N End Cap 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 _N ETU Maintenance Contract _,Y N provided Location of System on Property: Front R Left Side Righ Side Middle Front Middle Rear S m Use Sta Approved Partial Approved and n s to be re-inspected, please call the Building &Codes Office Disapproved L:\Parrs Whiting\2010\13ullding Codes Fbmis\Irtspecdon Fomts\Septic Inspection Report 03 2910.doc