PT-0330-2023 i
Property Transfer Sewage Disposal Information Form
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742 Bay Road,Queensbury,NY 12804 D v
P:518-762-8256 www.gueensbury.net JUN
3 2023
(Name of Owner/Applicant) ING$-CDpEU
Re: Onsite Wastewater Treatment System Inspection Information.Request for:
67- 17J.Jc,�,/ Ckxr_.r1tr_ jam_ a,y
(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. irior 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 11 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, j
A.
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John O'Brien,Director
Building and Code Enforcement
Town of Queensbury
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Property Transfer Packet Revised July 2022
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Office Use Only'
Permit#:
Fee: $ 2
742 Bay Road,QueensbuM NY 12804
P:518-761-8206 or 518-761-8205 Invoice#: 6Z03"
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: 5 DO J C,It-,J co�-,f— tj
Tax map number:
.Property owner: "Nlfl . w—a (,..�. � LC—'Nn/r•Jc,
Mailing Address (c/s/z): 2-4-y Lo 1--.-.c.- 7&A 1 ,3 .-,1 ya& ,- :5 d-4,4rO
Cell#: a Jl- Land Line#:
Email: c-E vJ 4-L- 5,
Applicant(if different than above):
Mailing Address (c/s/z):
Cell M Land ine#:
Email:
❑Proposed Owner ❑ Realtor ❑ Att r y ❑ Other(explain: }
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Septic Contractor: xe_ho ` _.Q
Mailing Address (c/s/i): RD �yo,� 1y3O SD Crr-rNS bus h}`� 1z'a3 03
Cell#: 519-?iS- qY Kg Land Line#: 519 - SSA--
Email: +ke
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Reason for Inspection Request:
❑On the market ❑Future listing ❑Sale Pending reed Transfer ❑Other:
Property Transfer Packet Revised July 2022
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HOUSEHOLD INFORMATION
**PLEASE SEE SEPARATE PAGE FOR EXEMPTIONS**
# Bedrooms `'1 # Bathrooms 3 # Kitchens I Jacuzzi tub(s) LO Garbage grinder d
Onsite Wastewater Treatment System:
How many systems are on the property?
Year system(s) installed: -Tank 14z- Size of Septic Tank Lf k <<AP-33
Type of Absorption System: "J(141
Are all system components wholly within the property boundaries? r Yes ❑No
Are system plans available? ❑ Yes p/No
Does the system(s) serve multiple properties? ❑ Yes 240
If yes, describe
Maintenance:
Service agreement? [Q'Yes ❑ No; If yes, business' name
Date of last inspection 41%111 N/A❑ Date tank last pumped \1 ti3 N/A ❑
Frequency of pumping 2-3 N/A❑
11-�_-e5 /yCO3V -
List known repairs/replacements, with dates:
Date Type of Repair/Replacement
2fl y-� G2�v..f ��•.-� acl.as�-,ti,. 5����--
Operation:
System problems? ❑ Yes No
. Sewage odors? ❑ Yes [9�No
Direct surface discharges)?. ❑ Yes VLNo
Back-up of toilets? ❑ Yes a No
Back-up of any other fixtures? (e.g. slow drains) ❑ Yes at No
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/'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.renewai
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: Wowner ❑agent ❑other:
Please print name: aev-r cr
Signature: `� . Date: 3
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
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TOWN OF QUEENSBURY
APPLICATION FOR SEPTIC DISPOSAL PERMIT Permit #
Fee Paid
Date: September 6, 1991 Reviewed By.
LOCATION OF PROPERTY FOR INSTALLATION: Box 96, Gunn Lane, Cleverdale
Owner's Name: Ted and Margaret Hans
Owner's Mailing Address: Box 96, Gunn Lane
Installer's Name: Scott McLaughlin Contractors, Phone #: 656-9589
nc.
Number of bedrooms (if residential ) : Three
Total daily flow (residential-compute @ 150 gal . per bedroom):
450 gallons'
Topography-Circle One: Flat Rolling Steep Slope % of Slope
Soil Nature-Circle One: Sand Loam Clay Other /Depth:
Ground Water-At What Depth? Feet
Bedrock or Impervious Material-At What Depth? Feet
Percolation Test-Circle One: Not Required Required/Rate Min. Per Inch
Domestic Water Supply-Circle One: Municipal Well Other
If domestic water supply is a well -
Separation: Water supply from any septic absorption feet
PROPOSED SYSTEM: - Septic Tank gal inimum size: 1,000 gal . )
Tile Field: Each Trench //Total System Length feet
Seepage Pit(s): Number of 'ze each: Ift. x ft.
Size of Stone t ed: # / Depth or Thickness feet
HOLDING TANK SYSTEM IF REQUIRED
No. of Tanks _ Size of Each �� Gals
Alarm system and associated electrical work to be inspected by a certified
agency.
I have read the regulation on the reverse side of this sheet and agree to abide
by these and.all requirements of the Town of Queensbury Sanitary Sewage Disposal
Ordinance.
SIGNATURE OF RESPONSIBLE. PERSON: ' ' DATE:
Note: Four 1,000 gallon holding tanks existing in recently installed
system.
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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: 23 June 2023
To: Bob & Liz Glenning
(Applicant)
Re: System Inspection Site Report for:
5 Duncan Cove, 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 from23 June 2023, the date of the inspection.
Sincerely,
A
John O'Brien, Director
Budding & Codes Enforcement
Town of Queensbury
/kd Revised March 2022