Revised application Office Use Only
OW, Permit
SEPTIC DISPOSAL PERMIT APPLICATION
�`• Permit Fee: $ ; Invoice #:
r �F�� ���h � Septic Variance? Yes No
awn742 Bay Road,Queensbury,NY 12804 t
P: 518-761-8256 www.queensbury.net RE /ICECVJ --�.-�.---
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Tax Map ID #: 301.20-2-1
I ig Queen Mary's Way - Lots 74 76 78 80 82 84 JUL 2 9 2020
Project Location: ry
TOWN OF QUEEN RY
BUILDING& CODES
• Applicant:
Name(s): Queen Victorias Grant Homeowners Association - Gary Nelson
Mailing Address, C/S/Z: 3 Queen Ann Court Queensbury, NY 12804
Cell Phone: _( 518 ) 744-1925 Land Line: _(
Email: movinon42@gmail.corn
• Primary Owner(s):
Name(s): Queen Victorias Grant Homeowner's Association
Mailing Address, C/S/Z: Box A Margaret Drive Queensbury, NY 12804
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
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) X
Spa or Hot Tub Yes No
1981-1991 130 12 130 1560
Installed? (circle one) X
1992-Present 110
PARCEL INFORMATION:
Topography ✓ Flat Rolling Steep Slope %Slope
Soil Nature ✓ Sand _Loam _Clay _Other (explain: )
Groundwater At what depth? >8'
Bedrock/Impervious material At what depth? >8'
Domestic Water Supply ✓ Municipal _Well (if well,water supply from any septic system absorption is ft.)
Percolation Test Rate: per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size Note 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: 2 Cad 20'x42'
Holding Tank System Total required capacity? ; tank size ;#of tanks
NOTE: Existing 2,000 gallon septic tank to remain, secondary 1,500 gallon septic tank to be added to account for grinders
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: (A G t DATE: 7/Zs)/Z-C.D
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SIGNATURE: AC-) DATE: V7V2--C)
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Septic Application Revised February 2019