PT-0008-2023 Property Transfer Sewage Disposal Information Form
c1 r
Date:
Town orQueens ury
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.aip--ensbury.net
A V,
lle5llllm�c a
(Name of Owner/Applicant)
Re: Onsite Wastewater Treatment System Inspection Information Request for:
gl
(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. Priorto 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@queensbury.net
Thank you.
Sincerely,
John O'Brien, Director
BUi ding and Code Enforcement
Town of Queensbury
Property Transfer Packet Revised July 2022
(
Office Use Only
". :.= ,r Permit#: l —0008 -202
or Fee:
row _ .
742 Bay Road,Queensbury,NY 12804 1
P:518-761-8206 or 518-761-8205 Invoice#:
www.gueensburv.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.
�N/
Tax map number:
Property owner:.
Mailing Address(c/s/z):
Cell M . Land Line#: '
Email:
�' ,��/rim: . •
JAN 0 9 20�3.
Applicant (if different than.above):. T �N �-At
BUIL[�IlVG ...r O by
Mailing Address,(c/s/z): - Ct7C�1~S
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:
Properly Transfer Peckcl
Revised July 2022
HOUSEHOLD INFORMATION
"PLEASE SEE SEPARATE PAGE FOR EXEMPTIONS"
# Bedrooms # Bathrooms # Kitchens- Jacuzzi tub(s) Garbage grinder
Onsite Wastewater Treatment System:
How many systems are on the property?
Years stems installed: Tank 7 Size of Septic Tank /V/�T e of Absorption •N*
Y ( ) . p Type System.
Are all system components wholly within the property boundaries? es ❑ No
Are system plans available? [] Yes .J2 0
Does the system(s) serve multiple properties? [] Yes No
If yes, describe ):
Maintenance:
Service agreement? ❑ Yes 0'-'No; If yes, business" name
Date of last inspection N/A ❑ Date tank last pumped / Z w)z N/A ❑
Frequency of pumping N/A p ���G� .S����� ��� /�G�•
List known repairs/replacements, with dates: �9 ,
Date Type of Repair/Replacement
Operation:
System problems? ❑ Yes p�o
Sewage odors? El Yes No
Direct surface discharge(s)? ❑ Yes pl
b
Back-up of toilets? ❑ Yes °
Back-up of any other fixtures? (e.g. slow drains) ❑ 2 Yes o
Seasonal ponding or breakout of leach field? ❑ Yes [ No
Property Transfer Packet Revised July 2022
-Statement of:Acceptance.o"conditions :
agree to:
4i , 'Ensure that the-septic-tank(s) distribution:bok,(es)- :and%orseepage p.it(s), if any, will.
be,uncovered rior to.the;re :u'este'd ins ectiorn:�time�;
p G p :
• Have.::a,septage::hauler on site(`to:pu.mpthe tank.after*:the inspector verifies-flow :-
from:fiktu res);:. .
.Tank must tie pumped'' presence of inspector
Haman authorised irepresentative present at the:site; ;
• Allow the inspector-to verify.infor.mafion:provided. above,.°and to conduct_an
insp:ection.of.the indicated onste wastewater treatment system(s), including al1.l;.
system:components an;d ntee!or�ip,,I,y ,W,,ngin crawl spaces andt'sements.
To:thebez—OUrny`knowledge;-the Ihformation_,provided above:is:accurate.and I-acknowledge.
thefollowing : -
.After 1 year from..date of.submission`'a`nd:there"is no'activit°.:on this;+ ermit`.the. ermit will
Y . Y. p., , p
expire and will be,subjectto`submission;of a renewal.application and:payment of the renewal..
fee based on:the current fee schedule. =All-fees must be:paid PRIOR TO;-SCHEDUUIVG_any
ins ections'.;� ln,addition, ii he;. erm t':is withdr-awn`:30%'of;the fee is.retained by the Town,of..-
p p. .<.
ueensbu -
. �Q -
..
Signature-:of;property, owner,or authorized agent:"-.
Affiliation: _ caner p agents of e
Please print name:
Si gnature: _ Dates: a:Z I :ZZ-
rior to scheduling with tfe Town:of'Queensb'ury:you MUST:
1.Schedule a sewage'hauler=to b,6bmtite:to."p.ump,tank while.inspector is on.site.
Hauler should`arrive 30-45 minutes after'scheduled-tirne..with the Town of,Queensbury;s
Code Enforcement.Officer.
2. Expose'inlet and'outlet.of-septctank ,and/or.pump station;,expose:d-box,.expoe
any,seepage pit covers:
3. Excavate test hole in leach'field'mt 'ere-,is.no_d
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$2,000. 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 1st 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'.ai 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, togetherWith.a check payable to the Town of
Queensbury in the amount of$2,000. 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 $2000 will be forfeited.
�I
7JAM0 9 2023
Property Transfer Packet Revised July 2022
❑ During the,Q.WTS iris pectio.h'a f4ilure;of:t6e,8eptic,system was-determined.:Due=to winter-and
,frozen conditions;the:repair to,an existing OWTS could,not occur.or.a.new OWTS could.not,be'
installed before,the,.coaveyance,of teal:property.:I for der,to:'qualify-for;the:exemption;,a:notarized
affidavit from the new property owner:to complete the installation or repair,of the:septic system-within
six months:from the:date=ofthe conveyance of:ie91.`property;"or June.l' whichever comes frst;,must;be
file m d.with the=Building"and Codes Enfoiceen'Wffice.A 6he6k'pay4bleIo the Town of Queensbury in
the am4hdaointer n$ 0 ` ased upon.
the completion:of the repair or installation ofra.,newsept�c system and:a satisfactorybWTS-inspection.;
from fhe,Building:arid Codes Enforcement Office If Tthe;P'roperty Transfer:.i.nspecti Oft:is not
completed within 'that 6 (six)month,;or Jnne: st timefram6 :the1;$2000 will;be
forfeited:
There is a_record.of.a septic_sysierii inspection upon property;teansfer,permit-and inspection completed '-
and-passed within.the last'thtee_years.°please provide a.copv4this record:,
PLEASE READNOTICE THOROUGHLY: .
Failure to.-complete the.'inspeetion;'obia fi f-he permit.or:complete-ali•repairs%installations
identified,-in the_preced ng subsections of this"section withiwthe'-time provided.or:anysubsequent
::,deadline established by,the Building!and Codes Enfbkceirient'Office:will result in:forfeiture of the
moneys,held;in:escrow;.a►id the.Town mayuse such,.funds toward abatingthe conditions caused
by each_such:-violation,of this article.
V ...,. . . P , .. ,. PP
Ins.pections;must:aake place within;..one:.(1)year:ofsutimisMon ofta".com �leied a lication.,
inspections:scheduled:to.take place.after the one yea r;period wiffb'e°subject#o.submissik "=
of wrenewal application;.afi&payment of::the renewal.:fee based on,the:currentYfee.)K edule
*x zONLY::SIGN THISPAGE:IF°YOITAkEOPTING'FORA WAIVERREOUEST!I"_x;:.
,I have.,read:-and understand the above jipuge; .eguding_ _,expectations,and:possi ,_-fo feiture
of moneys-submitted to the.Town.ofQuednsbury for;an exetnpfion.request:
Seller:..
Print.Name: 1111
, ;.,
SgriNairie.: . . . - =Date;:, Z°?Z.,
Buyer:.
PrintName:, o,��� tit.. of�n�� /A.i✓.
Sign Name: �" Date: "=e 2<
PinprnyTtanster Packet
itOF�d iaty 2022
AFFIDAVIT OF J:OAN: IU4 MOYNIHAN
STATE-OF NEW YORK ) CEO VIE
O 9 Lv
SS.: JA�� e3 I U�
COUNTY OF WARREN )
TOWN OF'Q JEENSBURY
BUILDING& CODES
JOAN. M. :MOYNIHAN,;being duly sworn, deposes:and,says:
1. My.husband,, .G. Thomas Moynihan, Jr.,-5 nd I are:,the purchasers:under.contract
of the singld:farnily.residence.owned by Michael:Chrys and.located.at`81'
Assembly:PitRod.inhe Ton&Quees Prty")ry e :
2. The tax map number of the Property is 239.12-2-27..
3. We..exobdt'to:complete::the-closing;antl become;bWners of_theProperty on or
about,January:.3, 2023.,
4. We-intend to:install a new.septic system on-.the Property afterthe purchase.
Z. We do not intend to.occupy th:e Property until the new se
ptic.system is'.installed
and.approved..
6. 1 make-this affidavit in connection with-Ahe request-of Wichabl ,Chryslbr,an:
exemption from-the Town of Queensbury.onsite:wastewater treatment.;system
Property Transfer Law.Inspection.requirement:
7. I know that the Town of Queensbury°Will,rely dri,the.truth of this affidavit to
approve: Mr. Ch y's's exemption request:
OAN M. M YN.I AN'.
:Sworn to before.me
this 29t".day of.December, 2022.
JOHN H RICHAR 's
NOTARY PUBLIC,sTATE OF:NEW YORK.
Registration N.o::02RI4642169:
Nota. . u lic Qualified.in:Wanen;Co fity
My Commission Expires: fly