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PT-0151-2023 Property Transfer Sewage Disposal Information Form Date: c4 Ito 2 Town of Queensbury 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.gueensbury.net MICHAEL J.O'CONNOR (Name of Owner/Applicant) Re: Onsite Wastewater Treatment System Inspection Information Request for: 15 Pioneer Point (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 15t 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, TOWN OF QIJFEN U�RY Jo n O'Brien, Director BUILDING 2K CODi:S Bqi ding and Code Enforcement Town of Queensbury Property Transfer Packet Revised July 2022 Office Use Only Permit#: " 0►51- 20?3 Torn ofQ?mnsbuzy 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: 15 Pioneer Point Tax map number: 289.14-1-15 Property owner: Michael J.O'Connor c/o R. Daniel O'Connor Mailing Address (c/s/z): 7 Lake Street Natick, MA 01760 Cell#: (617)755-7921 Land Line#: Email: Daniel.00onnor@ropesgray.com Applicant(if different than above): -FO APR 0 2023 Mailing Address(c/s/z): 3-7 SUILDIFV' �NSBURY Cell#: Land Line#: Email: ❑Proposed Owner ❑ Realtor ❑ Attorney ❑ Other(explain: ) Septic Contractor: 0-n S L jei-S ear vi c2- — &e orq a pe-e Kos- Mailing Address(c/s/z): 1411 l-L:rze rrie. led j®ue.en S U Cell#: 371oa Land Line#: 519 - 779 2- --7 ZS-7 Email: Reason for Inspection Request: ❑On the market ❑ Future listing ❑Sale Pending ❑x Deed Transfer ❑Other: Property Transfer Packet Revised July 2022 HOUSEHOLD INFORMATION "PLEASE SEE SEPARATE PAGE FOR EXEMPTIONS" # Bedrooms # Bathrooms 2 _# Kitchens Jacuzzi tub(s) Garbage grinder Onsite Wastewater Treatment System: How many systems are on the property? I Year system(s) installed: Tank_, Size of Se tic Ta k (ti -b '`A n ' - 1 r d Type of Absorption System: � Ott?Lr `'�''' .l 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 1 G. �k s If yes, describe bS d( �r� c S N o+ Maintenance: Service agreement? ❑ Yes No; If yes, business' name / Date of-last inspection's tit- N/A ❑ Date tank last pumped �b Z� N/A ❑ Frequency of pumping N/A ❑ List known repairs/replacements, with dates: Date Type of Re air Re cement Aj /A Operation: System problems? ❑ Yes k No Sewage odors? ❑ Yes PNo Direct surface discharge(s)? ❑ Yes a No Back-up of toilets? ❑ Yes ;�d7 No Back-up of any other fixtures? (e.g. slow drains) ❑ Yes eR No Seasonal ponding or breakout of leach field? ❑ Yes No Property Transfer Packet Revised July 2022 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; • 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: Xowner ❑agent ❑other: c Please prin name: .L C L h_Q 1A Signature: Date: Prior to scheduline 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 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$2,006. 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 V 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$2,600. 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 July 2022 ❑ 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 r 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 a filed with the Building and Codes Enforcement Office. A check payable to the Town of Queensbury in theramount 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. I 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: K l L Sign Name: Date:3 t Lj Buyer: I ` \`��+1✓ l O �MrrG Print Name: � ��615 Q Sign Name: Date:__ ti r- I Property Transfer Packet Revised July 2022. r; I J Building&Code Enforcement / 742 Bay Road,Queensbury, NY 12804-5902 Town ofQueens6ury P:518-761-8256 www.gueensbury.net Property Owner Checklist for Property Transfer Law Inspection The following items must be completed prior to the inspection date or the inspection will be cancelled and rescheduled when all items have been accomplished: 1.All paper work submitted and fees paid 2.Water is on in the structure 3.All water fixtures tied to the plumbing system are accessible for flow testing 4.The inlet and outlet cover of the septic tank or holding tanks are exposed and removed 5.The distribution box is exposed and cover is open for inspection 6.Any seepage pits are exposed and the cover(s)are open for inspection 7.Any pump stations are open and covers expose for inspection 8.Any grinder pumps are exposed and accessible for inspection 9.Septic hauler is scheduled to pump septic tanks or holding tanks after water flow test is complete 10.A plot plan of septic tank,distribution box, leech field or seepage pits is completed with measurements off structure prior to end of inspection 11. Provide maintenance Contract if you have an Enhanced Treatment Unit(ETU)septic tank 12.All Floats for pump stations and holding tanks must be accessible for testing 13.Alarm panels need to be accessible for testing and free of trouble alarms 14.Any access covers or pump stations access covers below 12"will require extensions to be installed at time of inspection Please assure that all applicable items above are completed prior to the inspection date or the inspection will be cancelled and rescheduled to a later date Property Transfer Packet Revised July 2022 MAP REFERENCES _.._..._ .. —c _ WASTEWATER SYSTEM DESIGN aa- os��.r","ar's .r'ao,�wrr xv • mu F/rou, F- `�r-;u \t �: so-.e F \� -emuwr _ •,._ r ...: - - - noose I w '�,.✓ � �'"x�I' w�'ecf<pxArod"°"op` �.��°wrm-arw.vu ..,�n . _ �• b �"�° ` ENVIRO-SEPTIC PIPE SECTION "mroFdA: mmeg $ ' YI -[`P.4,� \ e'F _ y lr°52se'aor:.i �,_ n�c¢-xW`nep i•-: % Po +.mmw.n as¢ rm ar°�.r°Fs .�`•:-t t^ �'¢"259.Is.1.13`i •: TEST PIT ehrmB:R Fu:;-' -\`y� \\ ®0i o n Fl Y wi:sFa"w.r As•m 5�uc na, LOCUION MAP _ .ru wn SFr ama•m�5 sr e 1���; g`a r \� l 7 Scpne1c cvc ,w°ipmx J°"0 ,®,:"en0••®• SYSTEM INSTALLA77ON N07E5 rx,.rwn v W1- I ro w.w�aw F—eW�F x- / wen"n/ere or �FF 6 mWrA:awwrm 5 of nPw WASTEWATER VARIANCE SUMMARIES m a c w m r x a / \ 1 PLAN NEW '^'3n'wR^'c fr✓/�'.SF)°rLL sflBAwr 7. 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IF tlwt YKrALL ON°P:k�fWW "K r£mPA nR 61) • uxuW A'IIDw " A _ G,r VALSF loc,nac 005Y m"1 A0.pAn rrmc,m,ff SYSTEM MATEWAL SPECIFICATIONS Ss,gn rm Fsma Sa n5 o OSO cx.NCC45r mr ':' HmLCwm r¢paXcm omAx RSEPTIC pI ff 1TANK nNOTE vaf�xc rs a n¢r v�PSr"ferVOr M Fm rro ws n�PaC n ms CW,Ram AI:RIi o�a`°°a gL"WM AWN w xaWra.YrF.� m�a�m RN Wf0 WASEWATER REPLACEMENT T PLAN RECORD °1 prepared for: romD—) -n at e Midlael J.O'Connor,E71mbeth Uttle&Robert&Renee Uttfe smcNns sou.a RA®w rwa meAcr�sm m w:v swn,r-r w. a auos Jem uau ecFs,.n,a;sane svem rmr,.. ffwume 'man u,f51M°¢su'mar roAomc A"£srArai:¢� - — -- W°v`Wz na,raw Arlo rr rta. irm� mwF nru ,,uemRexmaFe-arutr ion rAnx53 w WrC AKAS 9utL W: FlrmA KAvr WF6YPi5w,C meClmGl YRun:rROR m Aiv0149xo WIP. srsrtu 5rs -wmnAt swt S sum w war w ¢IvmAmr rem dQum�Gry,Warm('ar.y,"Y m5�mm x_ro —15 PT-0151-2023 AxaFFm �r6aYr� ne;� rw Ymw e: 29m �FawW.Mffmnr -K6F.weYam�6 28914-1m�w�°m ,S�m ��n.�na v�F� �,� lv r arsicsimre�crsns eAaaume � In pA"n. �cv,A °p1r°I w Hutmins Enelnmanne 19718-01 O'Connor, R. Daniel 15 Pioneer Point EDUCED Property Transfer -- WAIVER STATE OF NEW YORK ) ss.. COUNTY OF WARREN ) R.DANIEL O'CONNOR,being duly sworn, deposes and says: 1. That Deponent, as Trustee of the Michael J. O'Connor Irrevocable Trust u/a/d November 23,2022,is the transferee of 15 Pioneer Point, Queensbury,New York by deed from Michael J. O'Connor,dated January 3,2023,which is to be recorded in the Warren County Clerk's Office. 2. That an Onsite Wastewater Treatment System Inspection was not able to be completed prior to the conveyance of real property due to inclement weather. 3. That an Onsite Wastewater Treatment System Inspection will be completed by June 1, 2023 and will be filed with the Town of Queensbury Building and Codes Enforcement Office. 4. That a check payable to the Town of Queensbury,in the amount of$2,000.00, shall accompany this affidavit and is to be be held in a non-interest-bearing escrow account and shall be released upon the completion of a satisfactory Onsite Wastewater Treatment System Inspection from the Building and Codes Enforcement Office. 5. That if the Onsite Wastewater Treatment System Inspection is not completed within by June 1, 2023,the$2000.00 escrow deposit will be forfeited. R.DANIEL O'CONNOR Sworn to before me this l day of March, 2023. Notary Public KRISTINA M. LAFOUNTAIN 'NOTARY PUBLIC-STATE OF NEW YORK No. O 1 LA6298913 Qualified in Warren County My Commission Expires March 17, 2� PROPERTY TRANSFER SEWAGE DISPOSAL INSPECTION LETTER V Satisfactory Compliance Notice Town of Qyccnsbury Building&Codes Enforcement 742 Bay Road,Queensbury, NY 12804-5902 P: 518-761-8256 www.gueensbury.net Date: 16 May 2023 To: R. Daniel O'Connor (Applicant) Re: System Inspection Site Report for: 15 Pioneer Point, Town of Queensbury, NY (Site Address) As requested, the Town of Queensbury's Building and Code Enforcement Department has made an inspection of the wastewater system components serving the property referenced above. All system components have been found, and are noted in the System Inspections Findings Worksheet. Inspector's observations: The system appears to have functioned adequately under past and present loading. There can be no assurance or guarantee of future performance for any period of time. Numerous factors, such as household water usage, leaking toilets, soil characteristics and seasonal ground water table fluctuation, as well as owner failure to manage and maintain the system, will affect its performance. This approval is valid for 3 years from16 May 2023, the date of the inspection. Sincerely, A John O'Brien, Director Budding & Codes Enforcement Town of Queensbury /kd Revised March 2022