PT-0023-2022 Office Use Only
Permit#: "?T.'`02�--Z�lL2
Taws ofiCkwen:bmy Fee:
742 Bay Road,Queensbury,NY 12804
P:518-761-8206 or 518-761-8205 Invoice#: �
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: 21, 25 Duncan Cove (PVT)
Tax map number: 226.16-1-7 and 22 .16—Y=9`
Property owner: Jeannette C.Vosburgh, Evan L. Connolly, Lisa V. Earl, Beverly L.Vosburgh,Jean Frances Garry
Mailing Address (c/s/z): P.O. Box 97, Cleverdale, NY 12820
Cell#: Land Line#:
Email: michaelgarry@garrygarry.com
Applicant (if different than above): Stephen and Meghan Orban c/o Stefanie Dilallo Bitter
Mailing Address (c/s/z): 162 Larchmont Avenue, Larchmont, NY 10538
Cell#: Land Line#: 518-832-6419
Email: sdb@bpsrlaw.com
❑ Proposed Owner ❑ Realtor ® Attorney ❑ Other (explain: )
Septic Contractor: Dennis MacElrov/EDP �a �p
Mailing Address (c/s/z): C E v E
D
Cell#: Land Line#: aJAN3 1 2022
Email:
TQUEENSBURY
BUILDING&CODES
Reason for Inspection Request:
❑On the market ❑ Future listing 0 Sale Pending ❑ Deed Transfer ❑Other:
Property Transfer Packet Revised April 2021
HOUSEHOLD INFORMATION
"PLEASE SEE SEPARATE PAGE FOR EXEMPTIONS"
# Bedrooms 6 # Bathrooms 3.5 # Kitchens ? Jacuzzi tub(s) Garbage grinder
(system services 2 dwellings: main house with 4 br,22.5 bath, 1 kitchen; cottage with 2 br, 27a,
1 kitchen)
Onsite Wastewater Treatment System:
How many systems are on the property? 1
Year system(s) installed: Tank 1 Size of Septic Tank 1960 +/-
Type of Absorption System: uncertain
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 ❑ 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
❑ 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 lst 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 REOUEST!!***
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: Y
Sign Name: Datek�VOl
Buyer:
Print Name:
Sign Name: Date:
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 anon-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 1st timeframe, the
$2000 will be forfeited.
❑x 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
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% of the fee is retained by the Town of
Queensbury.
Signature of property owner or authorized agent:
Affiliation: M owner p agent ❑other:
Please print name: c✓\�
Signature: Date: 12 13 J!Z I
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
`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% 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: ���^L
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
%
❑ 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 lst 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 REOUEST!!***
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: L155 G v
Sign Name: Date: ZC
Bum t3
Print Name: E V V05,F3tA
Sign Name: L�? Date:
Property Transfer Packet Revised April 2021
�a
❑ 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 1st 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: SI _ � Ie
Print Name: p U
Sign Name: a on 0r Date:J'.-J YV— V V \./U LY
Buyer:
Print Name:
Sign Name: Date:
Property Transfer Packet Revised April 2021
Statement of Acceptance of Conditions:
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;
e Have a se'p tage 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;
0 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: Owner ❑agent ❑other:
Please print name: TVqAl G/fA/V
Signature: •ram Date: 47/2-
Prior:to scheduiine 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 t
Code Enforcement Officer.
2. Expose inlet and outlet of septic tank, and/or pump station, expose d-box, expose
any-seepage pit covers. y
3. Excavate test hole in leach field if there is no d-box. '
r
k
Property Transfer Packet Revised April_3021
f
November 22,2021
Stephen and Meghan Orban
162 Larchmont Avenue
Larchmont,New York 10538 DW
meghanorban(a,email.com
stephen.orban(aD,gmail.com Via Email. daveh(a,gueensbury.net TDavid Hatin
Director, Building and Code Enforcement
Town of Queensbury
RE: Exemption for OWTS Inspection
21, 25 Duncan Cove, Town of Queensbury,Warren County
Dear Mr. Hatin:
Please allow this letter to serve as confirmation that we are under contract to purchase the
above captioned property. We are requesting a waiver from the Town of Queensbury for
inspection of the Onsite Wastewater Treatment System("OWTS") located at this premises and
are submitting this letter along with the Property Transfer Sewage Disposal Information Form
confirming the same.
As the Purchasers of this property,we hereby state and affirm that the property identified
above contains an existing OWTS that does not comply with the provisions of the Queensbury
Building Code. We and the Seller wish to forego an inspection in favor of installing an approved
OWTS within six(6)months of the transfer of the property or by June 1,2022,whichever occurs
first. We hereby confirm that such installation will take place as required by the Town of
Queensbury.
If you need further information regarding this request please contact our attorney Stefanie
Bitter t sdb(abpsrlaw.com or via phone at 518832-6419.
i�Orban ghan pOrban
Sworn to before me this day of 2021 _
HERNANDO AGUILAR
Notary Public,State of New York
No.01AG6357762
Notary lic Qualified in Westchester County
commission Expires April 24,201;7�