PT-0243-2023 Property Transfer.Sewage Disposal Information Forma
7`ourn ofQye 8
Date;; -4 e ko-20
uty
742 Day Road,Qu@@n5lbury,ICY 12804
P.518461nMG www.gueehsbuty.net _
CEUi'_
(Name of Owner/Applicant) LMAY 9Ll
Res Onsit@ W@5t@wat@r Tr-@atm@nt$ystem Inspection Information Request fo TOVVN OF 0UEErNS2 J
RY
8, CODES
(Site Addr@ss 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. Priorto our Inspection,we requ@st
this completed application, a site map indicating the location of the septic components and confirmation the
pr-@=insp@ction preparation (s@@ the last page of this packet) will be completed prior-to our rar-rivgh
Enclos@d 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 now the Town of Qu@ensbury's fee for this service is$5275, R@ advised that all fees must be paid prior to
scheduling the inspection, We require 48 hours notification prior to scheduling the Inspections
If the purchaser is requesting an exemption, please submit this application I long with a notarized letter stating
the septic system will b@ Inspected or repaired/replaced within 6 months from the date of the Property
Conv@yance or June V of the current,. or following year (whichever comes first), a map locating the septic
system and payment totaling$ZZ75 ($2000 r@fundable deposit plus $275 permit fee), The deposit is forf@it@d
If the owner fails to complete the mpairs or installation as stated above, 11
If you h_v@ anygu@stI_n_, pleas,_ balls
Phone., (518) 701=8256 Emalle kat@d6,queensbury,n@t
Thank you,
Sincerely,
John Q'IJri@n, DIr@ctor
Wjding and Cod@ Enforc@m@nt
Town of Qu@ensbury
Office use 001y
Permit : ' 0 Z43• ZQ 7_3
Totr'n af"[Zrccnsbun• Fe@:
25'
742 Day Read,queensbyry►NY 12604 I �Q) ��"
P.,516=761=s206 or 516=761=8295 invoice#:
www.aueensburyiet
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. par-cel map)
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Property address for inspecti(?n: l '��Et�'� ® 2'a r)Q _ Qo"iee-NS'Zj//y
Tax map number: Z�� .7 - I -- 316
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Property owner: 26-tN i V- �J- trwl ev- _ m — •i-m ui-ftU L.#W"I: ?
Mailing Address (c/s/z): -v3 tAyklv F-N (�I '3�1 IS'n�� i./ .Y�� 12q, iS
Coll#:�'t� - 3'117-) 9g-L Land Line#: i - $fig - 17 W
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Email: LAwL.c--Y C 5 MAtL C-0m
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Applicant (if different than above).,
Mailing Address (c/s/z):
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Cell #: Land Line#:
Email
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Prgposod Owner 0 Realtor Attorney Othor(explain: I )
Septic Cgntr'actgr.- 5A-0 r 1/ SEWS- SysiC�
Mailing Address (c/5/z): I qY
Coll#: Land Line#: ►FC) ciZ -72S7
Email:
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Reason for Inspection Request:
On the market ® Future listing Sale Pending ® Deed Transfer Cl Other:
Fropyty Trdngft-Ndot Repvl gd-duly 2022
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HOUSEHOLD INFORMATION
"PLEASE SEE SEPARATE PAGE FOR EXEMPTiONS's?p
# Bedrooms Z #J Bathrooms # Kitchens I Jacuzzi tub(s) Garbage grinder
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Onsite Wastewater Treatment System;
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How many systems are on the property? i
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Year systems) installed; Tank Z®07 Size of Septic Tank /000
Type of Absorption System;
Are all system components wholly within the property boundarie$? ERYes EJ No
Ara system plans available?y p M Yes 0 No �
Does the systems) serve multiple properties? [] Yes a No
if yes, describe
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Maintenance; Sm( -S d QJ tT L S
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Service agreement? 0 Yes No; If yes, business' name _ i
Date of last inspection 2,00`7 N/A Date tank last pumped N/A Ej
Frequency of pumping N/A E
List known repairs/replacements, with dates:
Date Type of Repair/Replacement
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Operation:
System problems' E] Yes No
Sewage odors? o Yes M No
Direct surface discharge(s)? Cl Yies [FNo
• Rack=up of toilets? Q. Yes a No
* Back=up of any other fixtures? (e.g. slow drains) Ej Yes No
Seasonal ponding or breakout of leach field? EJ Yes [,5� No
AFAp@ny Trmd@r A t@k9t ReVl§@d JNIY 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);
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Tank melt be pumped In presence of In5p ector
Have an authorized representative present at the site,
to Allow the inspector to verify Information provided abovle, 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 land 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 fe is retained by the Town of
Queensbury,
Signature of property owner or authorized agent;
Affiliation: owner ®agent [j other;
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Please print name; -3>A-fQ iv-1- : t-A-VoL.F_V- �2
Signature: Date, Sdq -2_0Z13
Prior to scheduling with the Town of Queensbury,you MUST:
1s Schedule a sewage hauler to be on site to pump tank while Inspector is on site.
Mauler should arrive 30.45 minutes after scheduled time with the Town of Queensbury's
Code Enforcement Officers
2e Expose inlet and outlet of septic tank, and/or pump station, expose d-box, expose
any seepage pit covers,
Se Excavate test hole in leach field if there Is no d-box.
Prop@q Truu§fir Pa&t P.Qvind July 2022
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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: 20 June 2023
To: Daniel LawlerJr
(Applicant)
Re: System Inspection Site Report for:
19 Reardon Rd Ext,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 from20 June 2023, the date of the inspection.
Sincerely,
A
John O'Brien, Director
Budding & Codes Enforcement
Town of Queensbury
/kd Revised March 2022