application Office Use Only
Permit#: 2d
I SEPTIC DISPOSAL PERMIT APPLICATION Permit Fee:$ -- • Invoice#:
Septic Variance? Yes ✓ No
Town ofQgeensbury
742 Bay Road,Queensbury,NY 12804 •
P:518-761-8256 www.queensbury.net
Tax Map ID#: 301.20-2-1
Project Location: Queen Mary's Way- Lots 74, 76, 78, 80, 82, 84
• Applicant:
Name(s): Queen Victorias Grant Homeowners Association-Gary Nelson
Mailing Address, C/S/Z: 3 Queen Ann Court Queensbury, NY 12804 r Ga s-_
Cell Phone: ( 518 ) 744-1925 Land Line: _( ) I DUI
Email: movinon42@gmail.com ism
• Primary Owner(s): TOWN OF Q!UEENSIF. Y
Name(s): Queen Victorias Grant Homeowner's Association BUILD If;;_;2d COD;z
Mailing Address, C/S/Z: Box A Margaret Drive Queensbury, NY 12804 111
Cell Phone:_( ) Land Line: _(
Email:
❑ Check if all work will be performed by homeowner only
• Contractor: Workers' Comp documentation must be submitted with this application
Contact Name(s): Stone Industries/Dean Burdick
Contractor Trade: Installation
Mailing Address, C/S/Z: 4305 Route 50 Saratoga Springs NY 12866
Cell Phone: _( 518 ) 232-6707 Land Line: _(518 ) 584-1048
Email: dean@stoneindustries.com
• Engineer(s):
Name(s): Hutchins Engineering PLLC
Mailing Address, C/S/Z: 169 Haviland Road Queensbury, NY 12804
Cell Phone:_( ) Land Line: (518 ) 745-0307
Email: thutchins@hutchinsengineering.com
Contact Person for Building.& Code Compliance: Dean Burdick
Cell Phone: ( 518 ) 744-1925 Land Line: (
Email: movinon42@gmail.com
Septic Application Revised February 2019
1
RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms: X gallons per =total daily flow
per day bedroom Garbage Grinder Yes No
1980 or older 150 Installed? (circle one)
1981-1991 130 - Spa or Hot Tub Yes No
Installed? (circle one)
1992-Present 110
PARCEL INFORMATION:
Topography ✓ Flat Rolling Steep Slope %Slope
Soil Nature ✓ Sand _Loam Clay _Other(explain: )
Groundwater At what depth?
Bedrock/Impervious material At what depth?
Domestic Water Supply ✓ Municipal _Well (if well,water supply from any septic system absorption is ft.)
Percolation Test Rate: 3 per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size 2.om-)gallons(min.size 1,000 gallons, add 250 gallons for each garbage cylinder or spa/hot tub
System Absorption field with#2 stone Total length ft.; Each Trench ft.
Seepage Pit with#3 stone How many: 4 ;Size:existing 8' diameter byi8'deep (see Note)
f-+`/���j1` Alternative System Bed or other type: P
Holding Tank System Total required capacity? :tank size ;#of tanks
NOTE: Re-stone existing 4 drywells serving#74, 76, 78, 80, 82, 84. Removed material to be disposed of on-site.
NOTES: 1. Alarm system and associated electrical work must be inspected by a Town approved electrical inspection
agency; 2. We will no longer allow systems to be covered until such time as an as-built plan is received and
approved. The installed system must match the septic layout on file—no exceptions. 3. As-built drawings must be
submitted prior to the inspection, if there has been a change to the submitted plans.
Declaration: Any permit or approval granted which is based upon or is granted in reliance upon any material
representation or failure to make a material fact or circumstance known by or on behalf of an applicant, shall be
void. I have read the regulations and agree to abide by these and all requirements of the Town of Queensbury
Sanitary Sewage Disposal Ordinance.
PRINT NAME: frU(PAJtA D A) Wiz-16-10
DATE:
(24
SIGNATURE: DATE:
Septic Application Revised February 2019