septic application Office Use Oniy_
SEPTIC DISPOSAL PERMIT APPLICATION Permit#: P otQotn - 202'a
W-C
Permit Fee: $ 1-5 ; Invoice#: 52-
Septic Variance? ✓ Yes No
Town ofQucensbury
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.gueensbury.net
Tax Map ID#: 289.9-1-25
Project Location: 30 Sullivan Road, Town of Queensbury,Warren County, NY
Applicant:
Name(s): Scott Erwin & Sheila Faella
Mailing Address, C/.S/Z: 30 Sullivan Rd, Lake George, NY 12845
Cell Phone: (347-835-0343 ) Land Line: ( )
Email: scoerw@gmail.com
• Primary Owner(s):
Name(s): Scott Erwin & Sheila Faella
Mailing Address, C/S/Z: 30 Sullivan Rd,Lake George,NY 12845
Cell Phone: ( 347-835-0343 ) Land Line: ( )
Email: scoerw@gmail.com
❑ Check if all work will be performed by homeowner only
• Contractor: Workers' Comp documentation must be submitted with this application
Contact Name(s): Adam Crosse -North Valley Construction
Contractor Trade: Construction
Mailing Address, C/S/Z: 3 Maple Dr. Porter Corners,NY 12859
Cell Phone: ( 518-701-5754 ) Land Line: ( )
Email: Adamcrosse@gmail.com
• Engineer(s):
Name(s): Hutchins Engineering PLLC
Mailing Address, C/S/Z: 169 Haviland Rd, Queensbury,NY 12804
Cell Phone: (518-745-0307) Land Line: ( )
Email: tutchins@hutchinsengineering.com
Contact Person for Building & Code Compliance: Adam Crosse
Cell Phone: ( 518-701-5754 ) Land Line: ( )
Email: AdamCrosse@gmail.com
Septic Application Revised February 2019
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RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms: X gallons per =total daily flow
per day bedroom
1980 or older 150 2 110 220 GPD
GPD/bedroom
1981-1991 130 Click or tap here Click or tap Click or tap here to
to enter text. here to enter enter text. Garbage Grinder Yes No
text. Installed? (check one) ❑
1992-Present 110 Click or tap Click or tap Click or tap here to
here to enter here to enter enter text. Spa or Hot Tub Yes No
text. text. Installed? (check one) ❑
PARCEL INFORMATION:
Topography ® Flat Rolling ❑ Steep Slope %Slope
Soil Nature ❑ Sand ® Loam ❑ Clay ❑ Other(explain: )
Groundwater At what depth?50
Bedrock/Impervious material At what depth? Click or tap here to enter text.
Domestic Water Supply ❑ Municipal ® Well (if well,water supply from any septic system absorption is_101_ft.)
Percolation Test Rate: 0.95 GPD/SF_per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size _1000_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_25_ft.; Each Trench 15 ft.
Seepage Pit with#3 stone How many: ; Size:
Alternative System Bed or other type:.
Holding Tank System Total required capacity?_1000_;tank size 1000_;#of tanks 1
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:Sheila Faella
SIGNATURE:Sheila Faella DATE: 12/07/2020
Septic Application Revised February 2019