PT-0635-2023 (0.55- 2023
YOi_riNE K Lake George
STATE Park Commission
KENNETH W. PARKER DAVE WICK t
Chairman Executive Director L5 D c 1 I t1n
October 03, 2023 OCT 0 5 20Z3
PETER AND MAUREEN STECIUK TOWN OF QUEENSBURY
175 ASSEMBLY POINT ROAD BUILDING LAKE GEORGE, NY 12845 & CODES
Re: Wastewater Inspection, 09/29/2023
Parcel #: 239.7-1-34
Address: 175 ASSEMBLY PT. 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://Igpc.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
Property Transfer Sewage Disposal Information Form
Town of Qyeensbui y
742 Bay Road,Queensbury,NY 12804 Date:
P:518-761-8256 rrv� rrv�,.,, 112
Peter Steciuk
(Name of Applicant)
Re: Onsite Wastewater Treatment System Inspection Information Request for:
175 Assembly Point Rd
(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 11t 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,
John O'Brien, Director
Bu4i�lding and Code Enforcement
Town of Queensbury
Property Transfer Packet Revised September 2023
Office Use Only
Permit#: PT-0635-2023
N/A
Fee:
742 Bay Road,QueensburV,NY 12804
P:518-761-8206 or 518-761-8205 Invoice#:
AA�L q.q!2!2.g,.2 .........................
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: 175 Assembly Point Rd
Tax map number: 239.7-1-34
Current owner: Peter Steciuk
Mailing Address (c/s/z): 175 Assembly Point Rd
. 518-369-7404
Cell #. Land Line#:
Email- peter.steciuk@nepsi.com
Applicant (if different than above):
Mailing Address (c/s/z):
Cell #: Land Line#:
Email:
F-1 Proposed Owner 0 Realtor 0 Attorney F] Other (explain:
Septic Contractor:
Mailing Address (c/s/z):
Cell #: Land Line#:
Email:
Reason for Inspection Request:
F-1 On the market E] Future listing E]Sale Pending F-1 Deed Transfer Other: LGPC
Property Transfer Packet Revised September 2023
HOUSEHOLD INFORMATION
"PLEASE SEE SEPARATE PAGE FOR EXEMPTIONS"
# Bedrooms 4 # Bathrooms 4 # Kitchens 1 Jacuzzi tub(s) Garbage grinder
Onsite Wastewater Treatment System:
How many systems are on the property?
Year system(s) installed: Tank 2008 Size of Septic Tank Type of Absorption System:
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 ❑ 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 ❑ 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 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 ❑ agent* ❑ other (specify):
Please print name:
Signature: Date:
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