septic application Office Use Only
'�; Permit#: —'�7 Z�-tp •
SEPTIC DISPOSAL PERMIT APPLICATION permit Fee:$ ; Invoice#:
Town oFQucensbury Septic Variance? V Yes No
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net
Tax Map ID#: 227.6-1-7
Project Location: 16 Mayflower Lane
• Applicant:
Name(s): Jeffrey Campbell
1474 Division Street Charlton, NY 12019 �`"
Mailing Address, C/S/Z:. � - r,
Cell Phone:_( 518 ) 470-4940 Land Line: _( ) E I)E "ugi U \' if
Email: jcampbell@bblconstructionservices.com l _�
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L.,
• Primary Owner(s):
TOW
same as applicant N! OF `I-fL-N LTLry
Name(s): 13L►fiIPPR:4
Mailing Address, C/S/Z:
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):
Contractor Trade: Morning Star Excavation &Septic LLC
Mailing Address, C/S/Z: 59 Blanchard Road Gansevoort, NY 12831
Cell Phone:_( ) Land Line: (518 ) 793-2290
Email: morningstarseptic@hotmail.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: tutchins@hutchinsengineering.com
Contact Person for Building & Code Compliance: Jeff Campbell
Cell Phone: ( 518- ) 470-4940 Land Line: ( )
Email: jcampbell@bblconstructionservices.com
Septic Application Revised February 2019
RESIDENCE INFORMATION: `existing garbage grinder to be removed
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) X
1981-1991 130 Spa or Hot Tub Yes No
Installed? (circle one) X
1992-Present 110 4 110 440
PARCEL INFORMATION:
Topography ✓ Flat Rolling Steep Slope %Slope
Soil Nature ✓ Sand _Loam _Clay _Other(explain:
Groundwater At what depth? >60"
Bedrock/Impervious material At what depth? >60"
Domestic Water Supply _Municipal ✓ Well (if well,water supply from any septic system absorption is>100 ft.)
Percolation Test Rate: 3:00 per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION: **new 1,250 gallon polyethylene tank
Tank size 1.250 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: ; Size:
Alternative System Bed or other type: Ellen GSF Sand Filter (2)trenches @ 37 LF=74 LF total
Holding Tank System Total required capacity? ;tank size ;#of tanks
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 NA,„,E. k�ti��S �" INSwv� DATE: 7/6 �/Z )
SIGNATURE: DATE-77(P/ ( )
Septic Application Revised February 2019
FILE COPY
July 10,2020 "" 4J
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:
TOWN OF QUEENSBURY
Town of Queensbury BUILDING&CODES
Building and Code Enforcement
742 Bay Road
Queensbury,New York 12804
Attention:John O'Brien
John,
As requested,this letter is to notify you that there is not a garbage disposal or Jacuzzi tub at 16
Mayflower Lane,Queensbury, New York.
Please feel free=to contact me at 518-470-4940 if you have any questions.
Th kyou
effrey Campbell
Property Owner.