SEP-0232-2021 SEPTIC DISPOSAL PERMIT office Use only
APPLICATION Permit#: 'ZER— 6 L�L-2021
rown oF(nccnshury Permit Fee:$ 85-
Invoice#: 5600
742 Bay Road,Queensbury,NY 12804 C
9
P:518-761-8256 www.gueensbury.net Flood Zone? Y D Reviewed By:
Project Location: 19 Moon Hill Place
Tax Map #: 289.7-2-3
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? (choose one)
1981-1991 130 Spa or Hot Tub Yes No
1992-Present 110 3 110 330 Installed? (choose one)
i
`4
I
PARCEL INFORMATION:
i Topography Flat Rolling Steep Slope % Slope
Soil Nature Sand Loam Clay Other, explain:
I
Groundwater At what depth? greater than 60"
Bedrock/Impervious material At what depth? reater than 60"
Domestic Water Supply Municipal Well Lake
(if well or lake, water supply from any septic system absorption is
ft.)
Percolation Test Rate: 1-5 per minute per inch (test to be completed by a
licensed engineer/architect)
PROPOSED SYSTEM INFORMATION:
Tank size 1,000 gallons (min. size 1,000 gallons, add 250 gallons for each garbage cylinder or
Spa/hot tub . existing tank to be reused
System Absorption field w/#2 stone Total length ft.; Each Trench ft.
Seepage Pit w/#3 stone How many: ; Size:
Alternative System Bed or other type: 15'X 30' pipe-in-stone bed
Holding Tank System Total required capacity? ; tank size
# of tanks
DECEOWE
APR 15 2021
Septic Application TOWN OF QUEENSBURY Revised January 2o21
BUILDING& CODES
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• .
Applicant:
Name(s):James&Sheri Whiting
Mailing Address, C/S/Zk 11 ,l -1Hill Place Queensbury, NY 12804
Cell Phone: Land Line: 518-798-1407
Email:
• Primary Owner(s):
Name(s): same as applicant
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email:
Check if all work will be performed by property owner only
• Contractor:
Contact Name(s): Doug Whaley's Ideal Excavating
Contractor Trade: Excavation
Mailing Address, C/S/Z:P.O. Box 390 Bolton Landing NY 12814
Cell Phone: Land Line:518-644-2225
Email:idealcp@aol.com
**Workers' Comp documentation must be submitted with this application**
Eneineer('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 Compliance in regards to this project: Doug Whaley/Tom Hutchins
Cell Phone: Land Line:
Email:
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. 4. If,for any reason,the building permit application is withdrawn, 30%of the fee is retained by the
Town of Queensbury. After 1 year from the initial application date, 100% of the fee is retained.
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: James Whitinq
SIGNATURE: �,,/ / � � t. DATE:
Septic Application Revised January 2021