SEP-0422-2021 Office Use Only
Permit#: SC—P- 04-22 -,40 2
Permit Fee:$ 1815
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www,aueensbury.net Invoice#;
Flood Zone? Y P
Reviewed By:�
SEPTIC DISPOSAL PERMIT APPLICATION r;
Project L �-� �1 C% D E C E a V E
Location: 1
LJUNL03 2021
Tax Map #: 3� _ y
TOWN OF QUEENSBURY
BUILDING&CODIES
RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms: X gallons per =total daily flow
per day bedroom Garbage Grinder Yes No
1980 or older 150 I Installed? (circle one)
1981-1991 130 3 Spa or Hot Tub Yes
1992-Present 110 Na
-- _ Installed? (circle one)
-_---
I PARCEL INFORMATION:
Topography ' -X,,— Flat Rolling Steep Slope % slope_
Soil Nature GX Sand Loam Clay Other, explain:
Groundwater At what depth? None encov \�V u
Bedrock/Impervious material At what depth? oiryq en,covv,�ec�� _......
Domestic Water Supply X, Municipal _Well , lake
(if well or lake, water supply from any septic system absorption is
ft.)
Percolation Test Rate: per minute per inch (test to be completed by a
licensed engineer/architect)
PROPOSED SYSTEM INFORMATION: I
- - - - -- .._.._ ._.a. - - .......
Tank size gallons (min. size 1,000 gallons, add 250 gallons for each garbage cylinder or
spa/hot tub
System Absorption field w/#2 stone 1 Total length ft.; Each Trench go ft.
Seepage Pit w/#3 stone How many: ; Size:
Alternative System Bed or other type:
Holding Tank System Total required capacity? ; tank size
# of tanks
septic Application Revised December 2020
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• A lic nt•
Name(s): ti S \. �.`
Mailing Address, C/S/Z: .✓ e
Cell Phone: _S ) IJa0 09 Land Line- _(S _) - ��Q
Email:)t,��1.
• Primary Owners :
Name(s): carCi
Mailing Address, C/S/Z:
Cell Phone:_( ) Land Line: _( 1 .._.) C11Z- 1ul-
Email: drei., ® c&-�cungpt&Q)n
O Check if all work will be performed by property owner only
• Contractor-
Contact Name(s):
Contractor Trade: �►
Mailing Address, C/S/Z: V%f c
Cell Phone:_� ) Land Link: _(SIK -1,48-01A
Email:
**Workers' Comp documentation must be submitted with this application**
• En ineer s :
Name(s):
Mailing Address, C/S/Z: .1
Cell Phone: _( } Land Line:
Email: P��C�NCI e-.,P (dam
Contact Person for Compliance in regards to this project:
Cell Phone: S 1 Land Line: _}
Email: is
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: 1V0.
SIGNATURE: DATE:! ?1—
Septic Application Revised December 2020
RUCINSKI HALL ARCHITECTURE
Ronald Richard Rucinski
Ethan Peter Hall
C
134 Dix Avenue
Glens Falls NY 12801
Voice 518 741 0268
Fax 518 741 0274
Email ephall@nycap.rr.com
21 Michaels Drive
14 June 2021
Mark Smith —Town of Queensbury Building Department
742 Bay Road
Queensbury NY 12804
Re: Installation of Replacement Sewage Disposal System
At the above referenced project location this office observed the installation of the new distribution
box and distribution laterals prior to backfill. The attached drawing reflects the leach field placement
as constructed. The existing tank was verified to be in working order as needed.. This installation is
acceptable to this office. If there are any questions please contact our office to discuss.
Regards,
Ethan ter Hall :a �
Architect
ii.►
- .22- 2-02,I
ECEONIE
JUN 1 4�2021
TOBUILDING OF U EENsB Y
&CODES
1