PT-0380-2023 Property Transfer Sewage Disposal Information Form
Date: A�2Lzo L21z2o
Town of Queensbury
742 Bay Road,Queensbury,NY 12804 -..,r„Rw,^
P:518-761-8256 www.gueensbury.net
j1jN 9
(Name of Owner/Applicant)
TOINAJ OF
Re: Onsite Wastewater Treatment System Inspection Information Request fo . BViLDINGUENSBURY
& OODsS
3
(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 11t 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@queensbu-ry.net
Thank you.
Sincerely,
John O'Brien, Director
Binding and Code Enforcement
Town of Queensbury
Property Transfer Packet Revised July 2022
Office Use Only
��w
Permit#: 'P� -� ZOO
Town of Qe'Ccns ury Fee:
742 Bay Road,Queensbury,NY 12804
P:518-761-8206 or 518-761-8205 Invoice#: 6 Z?
www.gueensbury.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: Teel QO ga
Tax map number: i�j �- —50
A
Property owner: � '121.(J
Mailing Address (c/rs/z):
Cell #: )�{-�( '�2� -Land Line#:
�D
Email: m4jpwl.6V, JUN
f�
Applicant (if different than above): ,O Nop
�veEN
Mailing Address (c/s/z): G OO �'Y
Cell #: Land Line#:
Email:
❑ Proposed Owner ❑ Realtor ❑ Attorney ❑ Other (explain: )
Septic Contractor:
Mailing Address (c/s/z):
Cell #: Land Line#:
Email:
Reason for Inspection Request:
❑On the market ❑ Future listing ❑Sale Pending [ 'Deed Transfer ❑ Other:
Property Transfer Packet Revised July 2022
HOUSEHOLD INFORMATION
"PLEASE SEE SEPARATE PAGE FOR EXEMPTIONS"
# Bedrooms, # Bathrooms_� # Kitchens l Jacuzzi tub(s) Garbage grinder
Onsite Wastewater Treatment System:
How many systems are on the property?
Year system(s) installed: Tank IC.�j Size of Septic Tank
Type of Absorption System: WSJ
Are all system components wholly within the property boundaries? [ Yes ❑ No
Are system plans available? Yes ❑ No
Does the systems) 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 f 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 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 myknowledge, 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: 'owner ❑ agent ❑ other:
Please print name:_ 1 1
Signature: Date: �o—•�t� ���
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
BUILDING PERMIT
VALUE $ 0 TOWN OF QUEENSBURY 95166
TAX HAP NO. 44.-2-29 No.
WARREN COUNTY, NEW YORK
PERMISSION is hereby granted to CHANDLER. RAYHOND & GAIL
OWNER of property located at 167 TEE. HILL RD. Street,Road or Ave.
in the Town of Queensbury,To Construct or place a SEPTIC ALTERATION
at the above location in accordance to application together with plot plans and other information hereto filed and
approved and in compliance with the Town of Queensbury Building and Zoning Ordinance.
1. O WNE R'S Address is
T E HILL RD. .RD1
Q EENSBURY NY 12804
2. CONTRACTOR or BUILDERS Name
Q EENSBURY SEWER .
3. CONTRACTOR or BUILDER'S Address
JAY SWEET
0
4. ARCHITECT'S Name
5. ARCHITECT'S Address
6. TYPE of Construction—(Please indicate by X)
SEPTIC
( 1 Wood Frame ( ) Masonry ( )Steel ( )
7. PLANS and Specifications
SEPTIC RWERATION AS PER PLOT PLAN SPECIFICATIONS
B. Proposed Use
S PTIC ALTERATION
$ 25 PERMIT FEE PAID—THIS PERMIT EXPIRES April 9 1997
(If a longer period is required an application for an extension must be made to the Building and Zoning inspector of the
town of Queensbury before the expiration date.)
Dated at the Town of Queensbury this 20 y of April 19 95
SIGNED BY for the Town of Queensbury
Building and oning Inspector
PIRP for
SEPTIC DISPOSAL I'.�Iz1VIIT' APR 121C�' SV, ,)
TOWN Or-%:UEENSUURY
Location of property fo.r Installation: ; BULDING AND CODE
) PEA MIT NUMi ER
Owner's Natne: JIA2 �f C�
Address:
Installer's Name: u.< �l p41� 'r rl.I: PAID
Phone #: ( ) -2 6 4_(
Number of bedrooms (if resiticnlial):
i
Total daily flow (residential -compute a) 150 gal. per bedroom):
Tolx,graphy: L] Flat Rolling 0 1 I 1 /
Slcc � Slope °n of Slope
Soil Nature: [Y] Sand F-1 i.oam clay Other /Depth:
Uround Water: at what depth? feet
Bedrock or Impervious Material: at what dcp1h7 feet
Percolation Test: Not Required Required/Rate min. per inch
Domestic Water-Supply: Municipal [ ] Well Other
If domestic water supply is a WEE : water supply From any septic absorption is Net
PROPOSED SYSTEM:
4;S t
Septic lank: DQ J gal. (minimum size: 1,000 gal.)
Tile field: cacti trench feel. / total system length feet.
Seepage Pit(s): number of / size each: ft. x ft.
Size of stone to be used: # / depth or.lhickness 2 feet.
IIOI.DINCI TANK SYSTEM: (if required)
Numbcr of tanks: Size of cacti: gal.
Alarm system arid associated electrical work to he inspected by a certified agency.
For your protection, please note that pursmint to Section 136-29 of the Code of the Town of
Queensberry, any permit or approval granted which is based u port or is granted in reliance upon
air), material misrepresentation or.lirilttre to make a material jrct or circumstance known by or on
behalf of art applicant, shall be void.
I have read the regulations with respect to this application and agree to abide by these and all
requirements of the Town of Queensbury Sanitary Selvage Disposal Ordinance.
Sienatrtre ofresponsible person: _ Date: ��
i
TOWN OF QUEENSBURY
BUILDING & CODE ENFORCEMENT
531 Bay.Road
Queensbury NY 12804
518-745-4447
SEPTIC DISPOSAL SYSTEM INSPECTION
Name
Location
Date Permit #
SOIL TYPE: nd-L am-Clay-
Results of Pe of ation Test-
(if applicable Rate-Minute/Inch
TYPE OF SYSTEM:`.
ABSORPTION FIELMI Total Length
Length of each tr�nch
Depth of trenches
Size of stone
SEEPAGE PITS: Nu er-
Si•ze - ft. x ft.
Stone size
PIPING: S e Type
Bldg. to Tank
Tank to Dist. Box
Dist. Box to Field Pit
Openings Sealed? Yes No Partial
LOCATION/SEPARATI S:
Foundation to Tank feet
Foundation to Abso tion feet
Separation of Pits _ feet
Conforms as per Plo Plan Yes No
LOCATION OF SYSTEM PROPERTY:
( e one)
F n - Rear - Left ide - Right Side
Mid Me Front - Middl' Rear
COMMENTS:
a o�
SYSTEM USE FPPROVEt VESNO
Arrived: 3 530
Departed: S
Building rnsjWctor
TOWN OF QUEENSBURY
BUILDING & CODE ENFORCEMENT
531 Bay Road
Queensbury NY 12804
518-745-4447
SEPTIC DISPOSAL SYSTEM INSPECTION
,
Name er'
Location
Da 20 I Permit #
SOIL E: a d Loam-Clay-
Results o Pe olation Test-
(if applic 1 ) Rate-Minute/Inch
TYPE OF SYS
ABSORPTION FI Total Leng h
Length of each ench
Depth of trenc es
Size of stone
SEEPAGE PIT: Number
Size - t. x ft.
Stone size 3
PIPING: SXze, Type
Bldg. to.Tank S
Tank to Dist. Bo V" `
Dist. Box to Fie /Pi yk —�—
Openings Sealed? e N Partial
LOCATION/SEPARATI S:
Foundation to Tank feet
Foundation to Abso tion feet
Separation of Pits f
Conforms as per.P1 o Plan Yes No
LOCATION OF SYSTEM PROPERTY:
le one)
ron Rear = Left ide - Right Side
1 e Front - Middlk Rear
COMMENTS:
SYSTEM USE APPROVED: YES NO
Arrived:
Departed: 427
Building rbtoector
TOWN. OF QUEENSBURY
BUILDING & CODE ENFORCEMENT
531 Bay Road
Queensbury NY 12804
518-745-4447
SEPTIC DISPOSAL SYSTEM INSPECTION
Name G �
Location
Date f Permit # L'A
SOIL TYPE: Sand-Loam-Clay-
Results of Percolation Te t-
(if applicable) Rate-Min to/Inch
TYPE OF SYSTEM:
ABSORPTION FIELD: Total�'Length
Length of each trench!/
Depth of trenches
Size of stone
SEEPAGE PITS: Numb$r-
Size - ft. /z ft.
Stone size
PIPING: /�i Size Type
Bldg. to Tank
Tank to Dist. Bbx
Dist. Box to F eld/P''t
Openings Seal d? es No Partial
LOCATION/SEP RATIONS
Foundation o Tank feet
Foundation to Absorption feet
Separatio of Pits feet
Conforms as per Plot Plan Yes No
LOCATI OF SYSTEM ON- PROPERTY:
(circle one)
Front - Rear. - Left Side - Right Side
Middle Front - Middle Rear
COMMENTS: /
Ile
v,,44 dxs cues /Z
/01
SYSTEM USE APPROVED: YES NO
Arrived: A4
Departed: 1/z
1
Building Inspector
IL
_ VW
LO
> M.�r �
"I have seen a observed.or believe I saw evidence of,
all ob)ects such as houm tirft Uees,fences,etc., /V Dr i✓e-11s Ivy rhiN
N r ri to shown on this dogmat.I also represent that I have
rsona measured distances set forth on the diagram." /s/-er"
pe � J g
SIGNATURE DATE
wx
RESOLUTION APPROVING A SANITARY SEWAGE DISPOSAL VARIANCE
FOR MR. RAY CHANDLER
RESOLUTION NO. 10, 95
INTRODUCED BY: Mr. Nick Caimano
WHO. MOVED ITS ADOPTION
SECONDED BY: Mr. Theodore Turner
WHEREAS, .Mr. Ray Chandler previously filed a request for two
(2 ) variances from certain provisions of the Town of Queensbury On-
Site Sewage Disposal Ordinance, such provisions being more
specifically that requiring that there be a 150 ' separation between ,
the seepage pit and a well or suction line, and
WHEREAS, a notice of public hearing was given in the official
newspaper of the Town of Queensbury and a public hearing was held
in connection with the variance requests on April 17, 1995, and
- WHEREAS, the Town Clerk advises that property owners within
500 feet of. the subject property have been duly notified,
NOW, THEREFORE, BE IT
RESOLVED,
A) that due to the nature of the variances, it is felt that
the variations will not be materially detrimental to the
purposes and objectives of this Ordinance or to. "other ,
adjoining properties or otherwise conflict with the
purpose and objectives of any plan or policy of the Town
of Queensbury;
b) that the Local -Board of Health finds that the granting of
the variances is- necessary for the reasonable use of
the land and that the variances are•, granted as the
minimum variances which would alleviate the specific
unnecessary hardship found by the Local Board of Health
to affect the applicant; and
c) that the Local Board of Health imposes a condition upon
the applicant that he must also secure .the approval of
the New York State Department of Health, and
BE IT FURTHER,
RESOLVED, .that the Town of Queensbury Local Board of Health
grants the variances to Mr. Ray Chandler allowing the placement of
the.. seepage pit:
1 . 95 ' from his well; and
2 . 100 , from his neighbor's well;
rather than placing it at the mandated 150 ' distance(s) , on
property situated at i33. Tee Hill Road, Town of Queensbury, New
York, and bearing Tax Map # : Section 44, Block 2, Lot 29 .
1
Duly adopted this 17th day of April, 1995, by the following
vote:
AYES . . . Mr. Caimano, Mrs . Monahan, Mr. Turner, Mr. Champagne
NOES None
ABSENT: Mrs. Pulver
A.
lElp, JOB H w z,�`-e ,� ► 3 3
SHEET NO. OF
WATER • WASTEWATER • STORMWATER CALCULATED BY DATE
SOLUTIONS SCALE
TOWN OF QUEENSBURY
�3UILDI C & d DEFT.
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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: 17 July 2023
To: Matthew Eberlein
(Applicant)
Re: System Inspection Site Report for:
133 Tee Hill 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 from14 July 2023, the date of the inspection.
Sincerely,
A
John O'Brien, Director
Budding & Codes Enforcement
Town of Queensbury
/kd Revised March 2022