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PT-0499-2022 Property Transfer Sewage Disposal Information Form ~' Date: 3 7i Z� Town of Queensbury 742 Bay Road,Queensbury,NY 12804 � '® '�� "•_� �e P:518-761-8256 www.gueensbury.net - g AUG I I & DlxmaG� G1(,e�. R n, .1 ry �. l ( L I' I U E,L J''v t Lj r7 y (Na de of Owner/Applicant) s J�'�4 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 15t of the current, or following year (whichever comes first), a map locating the septic system and payment totaling $2275 ($2000 refundable deposit plus $275 permit fee). The deposit is forfeited if the owner fails to complete the repairs or installation as stated above. If you have any questions, please call. Phone: (518) 761-8256 Email: kated@queensbury.net Thank you. Sincerely, 1��r�Cd h(G! John O'Brien, Director Bui Vlding and Code Enforcement Town of Queensbury Property Transfer Packet Revised July 2022 Office Use Only Permit#: Lam' - 2012: Town of(Lrcrnsbury Fee:_$ 2."Arr, 742 Bay Road,Queensbury,NY 12804 P:518-761-8206 or 518-761-8205 Invoice#: T� www.gueensbury.net Vlsmve -fib 1�1o©6 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: L5 CAL? LuY Tax map num �-ber: S -3 �{00 �7- e Cl - 2- Property owner: } r-j ft)a- - 1 Mailing Address (c/s/z): "1 u-C1 a- C,2lrZ} u Nj Cell 7,2q 0 bC} Land Line#:S 22S Email: her I Z26) Y1nGtj C0 �1/1 Applicant (if different than above): f� Mailing Address c s z : 9 l;ll 1 i f�(( Cell #: Land Line#: i TCli�r f tRi i L7i= L1C f Email: '-Ois��tt7 ❑ Proposed Owner ❑ Realtor ❑ Attorney ❑ Other (explain: ) Septic Contractor: Co 0 �� Mailing Address (c/s/z): ? LA ft L Q-IQ I�U Vcry Q Cell #: :A- GCI�4 560 Land Line #: Email:. Reason for Inspection Request: ❑ On the market ❑ Future listing ❑Sale Pending KDeed Transfer ❑ Other: Property Transfer Packet Revised July 2022 HOUSEHOLD INFORMATION "PLEASE SEE SEPARATE PAGE FOR EXEMPTIONS" # Bedrooms # Bathrooms # Kitchens C;Q1 Jacuzzi tub(s) Garbage grinder Onsite Wastewater Treatment System: How many systems are on the property? Year system(s) installed: Tank Size of Septic Tank 1 U Type of Absorption System: ge(U lQ_4 CtP H L Are all system components wholly within the property boundaries? AkYes ❑ No Are system plans available? ❑ Yes VkNo Does the systems) serve multiple properties? ❑ Yes Vlo If yes, describe Maintenance: Service agreement?t Yes ❑ No; If yes, business' name Co 0 S � C` Date of last inspection N/A14 Date tank last pumped �� �� 0 N/A ❑ Frequency of pumping _ V/A ❑ List known repairs/replacements, with dates: Date Type of Repair/Replacement Operation: System problems? ❑ Yes [�lo Sewage odors? ❑ Yes 0 Direct surface discharge(s)? ❑ Yes [�"o Back-up of toilets? ❑ Yes [�o Back-up of any other fixtures? (e.g. slow drains) ❑ Yes VN0 Seasonal ponding or breakout of leach field? ❑ Yes [INo 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: �wner ❑ agent ❑ other: Please print name: M C( C.( Signature: Date: 2 2-- 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 To Whom it May Concern: 11/08/2022 I am writing to request a 6 month extension to fix the absorption field at 97 Rockhurst Rd Queensbury NY 12804. 1 am placing $2,000 in escrow until the septic issue is fixed. Thank You Geraldine Eberlein GAIL M. FIORE Notary Public, State of New York Warren County#01 F16171888 22 Commission Expires July 30, 200J E _, - t_- „j . . _ a9 r 4 �T'Uz -99 - ZQ 2Z-- SERVICE CONTRACT FOR THE FUJI CLEAN TREATMENT TECHNOLOGY Ellsworth& Son Excavating, Inc. has.been contracted by Fuji Clean USA and their Authorized Distributor to provide you with the first two years of service,maintenance,and operation aswell as any warranty service should it be required. This contract has been paid in full on your behalf. This contract is provided in accordance with applicable state and local regulations. This contract, entered into between Ellsworth&Son Excavating, Inc. and Geraldine Eberlein"shall be.binding upon both parties in accordance with the conditions and terms set forth below: Contract Date: 04-24-2023 Term of Contract: 2 years. Location of Technology:property address: 97 Rockhurst Road Model: Fujiclean CE5 Maintenance and Other Services shall consist of- a. Inspection, Maintenance,and Operation:Service Provider agrees to inspect,.maintain and operate the Fuji Clean treatment system per the TN DEC and manufacturer's requirements.This includes but is not limited to the following: two service visits per year (6-month intervals). Service•visits will include performance of operation and maintenance activities detailed in the Operation and Maintenance manual; check the sludge depth to determine the need for pumping; inspection of the final effluent to determine proper operational performance;and - test the process parameters including,but not limited to DO,pH,and turbidity to maintain proper operation; b. 'Service Calls- Service Provider will provide services calls within two business days. Service Provider will apply a charge for labor,travel time and stripping for any.necessary replacement parts unless covered by the manufacturer's warranty. c. Completed inspection form will be submitted to local and state authorities as required. d. Contract is transferable in the event of sale of the home. The owner of the system agrees to use the system as outlined in the owner's manual.The owner also,understands that any abuse of the system may void the manufacturer's warranty. Owner acknowledges that the following items can overtax the biological process of-the-system and shall avoid introducing dental floss,disposable diapers, kitty litter,sanitary napkins,tampons,cigarette butts,condoms and other items of similar nature. Owner acknowledges that the following can destroy the biological process and agrees to not introduce chemicals such as paints,varnishes,thinners,waste oils, photographic solutions, pesticides and excessive amounts of household chemicals into the system.The owner acknowledges that violation of these terms will void the manufacturer's warranty and may be in-violation of state law. Homeowner: Date Service Provider Lz Date�r (Au o ized Agent) Please sign and return to the Service Provider whose name and address appear below: Ellsworth&Son Excavating,Inc 10302 State Route 149 Fort Ann, NY 12827 ENVIRONMENTAL DESIGN the -vsi(18 May 3, 2023 Town of Queensbury Building & Codes 742 Bay Road Queensbury, NY 12804 Attn: John O'Brien, Director Re: Eberlein/Mackey Residence — 97 Rockhurst Road Dear Mr. O'Brien: 900 Route 146 Clifton Park, NY 12065 (P) 518.371.7621 (F) 518.371.9540 edpllp.com \61 ss i.3 In compliance with application approvals granted by the Town of Queensbury I offer the following regarding the referenced project. The design plans, prepared by this office, reviewed and approved by the Town of Queensbury Board of Health and Town Building Department as associated with the wastewater system application, are as follows: Proposed Wastewater Replacement For The Eberlein Residence 97 Rockhurst Road, Town of Queensbury December 28, 2022 Sheet 1- Wastewater Replacement Plan Sheet 2- Wastewater Details During the course of construction Environmental Design Partnership LLP was on the job site to observe key components of the system installation on April 25, 2022. Components insepcted include, Fuji Clean ETU, 4' I.D. pump tank, pump components not installed at time of inspection, 17' x 33' stone absorption bed with orfices. I have provided an 'as -built' plan which indicates the system component locations, in accordance with the approved BOH variance and Town plans. Based on my inspection of the system installation it is my opinion that the wastewater system is in compliance with the intent of the approved design plan and is ready for operation. Sincerely, Connor DeMyer, Project Engineer. Attachment Cc: Geraldine Eberlein (geberlein0622(cDgmail.com) Wdweno SL" WFYI S'^VVegi.t>4eY.`MM1Neld PeAfleQ�dW-SWen YttTAtlOtl 15tlfIHH�Oth1tlf19SN33t1OW3tlWM\ZV Ufleeuwop-fly M1!ede+NS\dryueeVed WIfleeW�US3V^3'tIiMN0.M\� d0ap... 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'o'yN i Oy- c o x wx90 G� pcO� wLry m x ZZm iN� y � �u gpip iYn S � �doo Ny oz S a a�g rm a�3� _ man `3aizno¢�c 3i2a cwiw �o e:F Iw-ozo ow za m a ®J zI o ou .81 a oa r < GGpIIII� II _ _ — -I II' LIII=1 �I w ¢ (Lz dg III —II ow LO z N a MITI 8 K � I— � g= W > m n 36 illllll-�� �illl �IIII g� - dll II.� W I v O -III—I—III — — .-ill—III-II=,IGIII-II-=1�f-1�1_ - > Q \ Z �m Z IIIIIII 1= C—I_iI��I1JJ=11— w I I I m \i W vj �Fso4 'x of — o 1— �¢awoa a U s wswp Z Ez OZ p m F 0 d :� CL w r °_- z o 0o �a o w m z mz Wa N z w O X w E Trnv �g i i o 00g aQ >° s xp w 9 g ID _ aa w Qn5 o N > U a Za Q !r � m W d o o z o 0 o U Z w w r a. w N N ! ffi mo um a a� g a z p'a � 9 x z� a o Gg a V U O O Q Ua, l-i m z m i n z w G� oho °1 0 G Q E O m �o o o 6w I �p = c o LL E ba & _ � p _ �_ 3 p OR U U c W O. a u m ood W r-w a z «` U W `oomz w m o �s C r6 U U b b b b z yy io: zoi i _ @ U O O FiF ciao N 2 d tC w W N� F F Fw F O V a- u w �N w4 oQF z p z d c Nm N ® m $g 6 _ ooi G mao ��� $ oG iz3 (4 Q Q U 0 ZF z im z3 z o dpa� u z ��z G wrcz O D O ®©EL <mpp H sm $� s 700 I— i 1z U @gyp O M , m O Z F- w u F� za a O pO ° 0 J U� wp w� w0 0 J Z J o J J Z J m WK my O LLQ: N_y^m E� Q U n CIF bG Li w Q FYa- I ? o a n oho LLI 7 C7 0.1 Q [� m war,' J oC w in h IIIo a wiz Z w _ o w W III— o f of x w � � LLo W aj/ ItE �� _p mZ > m © Q IE �aF a b a'REo o o� z Q'_ _ W0 po m w O uII N� Go zd LL m OU FS Li V ! m �I" () U w N w W �s a �I �� U) Z w 0 W `v O Q moLIJ o '6Y wa W a.} J W z z o f U 3�o v gw w O O-----in �--- W a w =� O U �1� H -� a 3o a 1� Z 11- Z Q U W " by c � � v d < Zp W m in z Z W v Z O N a a�� w d w a U c E r Q�U� "n.0 m `o Ua>n.> mL LL p- ,aaNLLaaU U m a U c U O t0 O Q N N o C ~ � � a> � 0 3 Y c to m w c QN�QmFm-Q.QO 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: 18 May 2023 To: Gerald and Rosemary Mackey (Applicant) Re: System Inspection Site Report for: 97 Rockhurst Rd,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 from18 May 2023, the date of the inspection. Sincerely, A John O'Brien, Director Budding & Codes Enforcement Town of Queensbury /kd Revised March 2022