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PT-0677-2023 PROPERTY TRANSFER SEWAGE DISPOSAL V Satisfactory Compliance Notice per LGPC Town of Qyccnsbury Building&Codes Enforcement 742 Bay Road,Queensbury, NY 12804-5902 P: 518-761-8256 www.gueensbury.net Date: 26 October 2023 To: Stephanie &John Mason (Applicant) Re: 11 Heron Hollow Rd, Town of Queensbury, NY (Site Address) As requested, the Town of Queensbury's Building and Code Enforcement Department has reviewed the wastewater inspection letter provided by the Lake George Park Commission (LGPC). Per their findings, all components have been found to be compliant. Please be advised that, while the system seems to be functioning 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 five (5) years from24 October 2023, the date of the LGPC inspection. Sincerely, A John O'Brien, Director Budding & Codes Enforcement Town of Queensbury Property Transfer Sewage Disposal Information Form T• Toirn OfQureacbury 742 Bay Road,Queensbury,NY 12804 Date: 10/24/23 P:518-761-8256 www.queensbury.net JOHN A & STEPHANIE B. MASON (Name of Applicant) Re: Onsite Wastewater Treatment System Inspection Information Request for: 11 HERON HOLLOW ROAD, QUEENSBURY, NY 12804 (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 scheduling an inspection with the Town of Queensbury,we require the following: • this completed application • a site map indicating the location of the septic components • the pre-inspection preparation (see the last page of this packet) is completed prior to our arrival • the appropriate fee(s) are paid: $275.00 (an additional $2000.00 refundable deposit, if you are requesting a waiver) • the appointment date/time that your septic hauler is scheduled to pump out your tank. We require 48 hours notification prior to scheduling our inspection. If an exemption is requested, 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) • the map locating the septic system • payment totaling$2275($2000 refundable deposit plus$275 permit fee). The deposit is forfeited if the owner fails to complete the repairs or installation as stated above. If you have any questions, please call. Phone: (518) 761-8256 Email: kated@queensbury.net Thank you. Sincerely, - lE O V E OCT 252023 TOWN OF QUEENSBURY John O'Brien, Director BUILDING&CODES Building and Code Enforcement Town of Queensbury Property Transfer Packet Revised September 2023 Office Use Only Permit#: P \ ' 010 c r- 2023 Town of Cte eensbury Fee:_$ � �- ��•WI). 742 Bay Road,Queensbury,NY 12804 P:518-761-8206 or 518-761-8205 Invoice#: www.queensbury.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: 11 HERON HOLLOW ROAD, QUEENSBURY, NY 12804 Tax map number: 227.17-1-3 Current owner: JOHN A & STEPHANIE B MASON Mailing Address(c/s/z): PO BOX 86, CLEVERDALE, NY 12820 Cell #: 518-361-2767 Land Line#: 518-656-9956 Email: sunsoval@gmail.com Applicant (if different than above): Mailing Address(c/s/z): Cell #: Land Line#: Email: ❑ Proposed Owner ❑ Realtor ❑ Attorney ❑ Other(explain: Septic Contractor: SUNSOVAL, INC. Mailing Address (c/s/z): PO BOX 86, CLEVERDALE, NY 12820 Cell it 518-361-2767 Land Line#: 518-656-9956 Email: sunsoval@gmail.com Reason for Inspection Request: ❑On the market ❑Future listing ❑Sale Pending 0 Deed Transfer ❑Other: Property Transfer Packet Revised September 2023 HOUSEHOLD INFORMATION **PLEASE SEE SEPARATE PAGE FOR EXEMPTIONS** # Bedrooms 5 # Bathrooms 4 # Kitchens 1 Jacuzzi tub(s) 0 Garbage grinder 0 Onsite Wastewater Treatment System: How many systems are on the property? 1 Year system(s) installed: Tank 2009 Size of Septic Tank 1000Type of Absorption System: STD Are all system components wholly within the property boundaries? ['Yes ❑ No Are system plans available? ❑■ Yes ❑ No Does the system(s) serve multiple properties? ❑ Yes 10 No If yes, describe ): Maintenance: Service agreement? ❑ Yes ❑i No; If yes, business' name Date of last inspection 10/23 N/A❑ Date tank last pumped 10/23 N/A❑ Frequency of pumping 5 YR N/A ❑ List known repairs/replacements, with dates: Date Type of Repair/Replacement 10/09 NEW SYSTEM Operation: System problems? ❑ Yes ❑� 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 Packct Revised September 2023 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 one (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: ❑attorney El agent* El other (specify): Please print name: J O H N A MASON Signature: - Date: 10/24/23 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. *see Agent Authorization signature page Property Transfer Packet Revised September 2023 7T- © ��� � 20Z� f" Y�K Lake George STATE Park Commission KENNETH W. PARKER DAVE WICK Chairman Executive Director1E %1 79 D �y October 24, 2023 i1 JOHN MASON d OCT 2 5 2023 POST OFFICE BOX 86 CLEVERDALE, NY 12820 TOWN OF QUEENSBURY BUILDING &CODES Re: Wastewater Inspection, 10/24/2023 Parcel#: 227.17-1-3 Address: 11 HERON HOLLOW RD , NY NOTICE OF COMPLIANT WASTEWATER SYSTEM Thank you for coordinating a wastewater inspection with the Lake George Park Commission. The above-referenced inspection conducted at the subject property indicates that the wastewater system onsite is designed and functioning in satisfactory compliance with applicable standards. Please maintain a copy of this letter along with all other pertinent documents for the life of the wastewater system (e.g. pump out records, inspections, repairs, permits). The next wastewater inspection for this property will be due in 2028. In the interim, so as to prolong the proper functioning of this system, please continue to employ best management practices in the use and maintenance of your system. Resources concerning best management practices can be found on the Commission website: http://1gpc.ny.gov/septic-systems If you have any questions regarding the Commission's wastewater management program, please feel free to review our online resources or reach out to the Commission office using the contact information below. Thank you again for your consideration. Your interest and efforts to protect Lake George water quality through effective wastewater management is sincerely appreciated. Dave Hatin Engineer Technician II Lake George Park Commission PO Box 749, 75 Fort George Rd, Lake George, NY 12845 (518) 668-9347 I fax (518) 668-5001 Septic@Igpc.state.ny.us { (518) 668-9347 I fax (518) 668-5001