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SEP-0463-2021 SEPTIC DISPOSAL PERMIT office Use only APPLICATION Permit#: DC4 - o lQ3 ' 2921 Town ofQueensbury Permit Fee:$ CV�8q-�pp D Invoice#: 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.gueensbury.net Septic Variance? Y Flood Zone? Y Wetlands? Y Reviewed By: Project Location: 159 CVn2S4-ny+ ?-�Clne 9-©Rp 1HE Tax Map M 2cl0 .•-I -22, 6 2021 RESIDENCE INFORMATION: TOWN OF QUEENSBURY BUILDING&CODES Year Built Gallons #of bedrooms: X gallons per =total daily flow 1perclay bedroom Garbage Grinder Yes No 1980 or older 150 Installed? (choose one) ❑ 0 1981-1991 130 Spa or Hot Tub Yes No 1992-Present 110 �'j 1 l © Sc�d Installed? (choose one) ❑ PARCEL INFORMATION: Topography Flat Rolling 0 Steep Slope % Slope - Soil Nature X Sand ❑ Loam ❑ Clay , ❑ Other, explain: Groundwater At what depth? N V E Bedrock/Impervious material At what depth? N E Domestic Water Supply ❑ Municipal Well ❑Lake (if well or lake, water supply from any septic system absorption is 15Dt ft.) Percolation Test Rate: 1-6 per minute per inch (test to be completed by a licensed engineer/architect) PROPOSED SYSTEM INFORMATION: Tank size MC) gallons (min. size 1,000 gallons, add 250 gallons for each garbage cylinder or spa/hot tub 1voo 0x ji,, i5co N-e- vJ 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: �-1 ' Y 35 Holding Tank System Total required capacity? ; tank size # of tanks Septic Application Revised April 2021 CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL • Applicant: Name(s): C.- 0--5--fte-r �I Mailing Address, C/S/Z: �� S�-�� 12iGt �e� . C � �►'» , Cell Phone: 5 _iLlF- 2D I Land Line:.5119 _4Lf Email: 1-61C-aSfiLer'6Jwi4 CiDfy) • Primary Owner(s): _ Name(s): I-ex-41 CL Q n AiawV_g CaSf I -'_ Mailing Address, C/S/Z: 5 Me A Abov-e- Cell Phone: it Land Line: Email: of ❑ Check if all work will be performed by property owner only • Contractor•.Contact Name(s): A+n d Li 4AVI +°1 Contractor Trade: c Mailing Address, C/S/Z: '1p Harn6oj Alf?0bq j 5 6-F lgyo3 Cell Phone: 511 4q(P - SI 3 I Land Line: Email: ffC-'lV-(05_A1dr6W0,tyaJ1OD . C)rl� "Workers' Comp documentation must be submitted with this application" • Eneineer(s): Name(s): V.UG111 ," CTUqz-C_ Mailing Address, C/S/Z: ►?- 'O I X �'�l'F QiI , _S FDA(� M\-' Cell Phone: Land Line: 518—ICI-1 0 2(o g Email: E PWALL Cam? NYJ CAP. I?ii2 ,&0" Contact Person for Compliance in regards to this project: Cas Cell Phone: Land Line: 51 5'r 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.) have read the regulations and agree to abide by these and all requirements of the Town of Queensbury Sanitary Sewage Disposal Ordinance. 1 PRINT NAME: IlaS�-I,�V SIGNATURE: DATE. Septic Application Revised April 2021 RUCINSKI HALL ARCHITECTURE Ronald Richard Rucinski Ethan Peter Hall 134 Dix Avenue �JG Glens Falls NY 12801 Voice 518 7410268 Fax 518 741 0274 Email ephall@nycap.rr.com 139 Chestnut Ridge Road 16 November 2021 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 septic tank and gravity stone bed prior to backfill. This installation is acceptable to this office. If there are any questions please._contact our office to discuss. Regar Di Ethan Peter Halls.. Architect AS BUILT OZ704N OP rox p E C E 0 V E NOV 16 2021 TOWN OF QUEENSBURY BUILDING & CODES 1