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SEP-0562-2021 _. .. Office Case C?IiIV.. 'Perm t , � 2 - ZQJ2,.l i sir r(:tgutsx xa-:7. Permit Fee:$ 7!12 day Etoad Queenstaury,NY 12804. - Pc:5 8?61=8256:wtnimgueensbury.net Invoice %4 FI©od Zone? Y �� 6viewea, ,SEPTIODISPO:SAL:PERMIT APPLICATION Pro+ ect Location: 'Tax:Map#� RESID NCE:INFORMATION: _ Yea�::Bui(t Galion' #of.bedrooms. X gallons per' total daily flow I per.day. . bedroom t Garbage-Grinder Yes: :N :1980.&oldet 150 ' Installed?.: circle one 19$1=1991. 130: Spa nr Hof'Tub Yes ..- - -...... 1992=Present: 110 one In. sta e - circ e: PARCEL INFORMATION:. Topograpl }r Flat Rolling Steep Slope 1 Slope: € soil Nature Sand Loam: yE .C—El ' ... . D .:Groundwater At.w . t:depth7 Bedrock .l:mperui;vus;matei'ia( At;: hat depth: -- O.o6ietic:Water Supply. 1ltlunicipal ^Well TQV"F QUEENSBURY' URA g&C DES {if well or lake, grater supply front a: iS. ft.} Percolation Test Rate: per Minute.per.,inc test to be>.deted by a ;:licensed:engin.eer/architect} PROPOSEDSYSTEM;INFoAMA ION: Tan.., size gallons : min. size.1,000.gallon's add 250_gallons for each:garba.gat inder or �. t. . s a .hot tub P / System Absorption.field W/#2 stone Total length f� ft4 Ekh.Tren.ch ft.. e Now many:.. ; Size: eepag. Pit w .#3 sta.ne _... Alternative System. fed or other type: Holdin Tank S stem Total re u�red capacity.? tank:size. . I? v q , #`of tanks Sep tic.Application Revised Qecember;2020 ..-..:j....... B .. ...._ CC?NTAGT..INFQRMATIQN:_PL:EASE,PRINT LEGIBLY RJR.TYPE, PLEASE INCLUDE AN,:EMA{L i •: :A licant: i V) Wiling-Address, C/s/Z: CeII Phone . _ Land Line:: ) E mail: 1`��� ►_ �� .f"S-h ', .Ccyy-) G :. PrimarY:C)wner s ;: f rl (�. ... .... .. . Mailing:Address C/S - Cell:Phone: Land.Line: -( ) Emaif:: El Ct ec'k if all work will be: erformed by prope.rty owner.o N •: 'Contractor:: CpntactName(s} CoritractorTrade: CbG Mailing Address,:;C/s/z:. ��. (.�.:.. . ..::.. .... Cell,Phone: } - Land Le:in _(.-'1 } Email.......... . . .... ... "Workers' Comp:�docum ntation-M usttbe submitted ith this:.00licetioa." • Engineer(s): Name(s):: Mail ng;Address;CNI'l: . Cell Phone:;_{. ) Land_Ltne: �( } Contact Person for Compliance' ri regardstothis project: Cell -Phone-::(. Land Line: 1 } ...:. Em.ail� NOTES- 1:,Alarm:system and associated electrical work must be Inspected:bvaTciwn:approvod:electricaI inspection agency,2.11ti1e will no longer al low systems.to be covered.until such tirne as.an as�builfi plan is received:artd:approved.The installed system:must match the septic::l.ayout on file---no.exceptions.3,:As- built.'dravi ings i�ust:be subrriitted:prior ty the.inspectian; if`there [1as:beeri a change to:.the::sut3mitted plans. :lf,fa any reason,.the.building permit application is withdrawn,:80% of-th-T e:is retained:bv the TbWn.'of Queensbury. After 1 year`from the initial;appliCation date, 100�0 of:the.lee s retained.. Declaration::Any:`permit.or approval granted:which is.based::upon or ts;granted,in::.reliance upon any rrmaterial representatign on.-or failure to rriake:a material factor circurn9tance known:by or on:behalf-af an appltcar t,shall be void:l have;read the regulations and;agree to abide by th se and.all requirements of the ToWn of:Qiaeensbury sanitary.Sewage-Disposal ordinance. PRINT.NAME::: . ti, Lprl ;: ::. SIGNATURE: PATE:�^ SepticApptfcation, Revised December2020 TOWN OF OLIBENSBURY 742 Bay Road, Queensbury, NY.. 12804-5902 Septic System checklist Plan to scale Received Deep hole perc test results from engineer/Architect if applicable(Town Approved Engineers and Architects;June 30 to April 15 Town Engineer for unapproved Engineers and Architects) All wells on property and adjacent properties shownY water line shown Municipal or well 10'separation to any part of system XSetback to property lines show 10'or more for any part of system Septic tank and pump stations 10'from foundation 50'from any well/lake/wetland 10'from any waterline Septic tank to foundation crawl space/slab on grade,grade in crawl space must be above top of septic tank for 0',Separation required (field verification required) Septic tank sized for number of bedrooms and add 250 gals for Jacuzzi tubs/garbage grinder each Leech Field 20'from foundation 100'from any well 10'from water line U-)N Seepage pit 150'from well 50'from.septic tank Seepage Pits 3-times diameter apart Septic tank and pump stations over 30 gallons 50'from watercourse or wetland distance from bottom of trench or syste edrock or mottling 36"within 1000' of Lake George Leech field 100'from watercourse or wetland Toe of mound or bottom of retaining wall 10'from property line 100'from well 20'from Foundation C,0 0 O—Provide Engineer/Architect stamp for bed or design systems l Department of Health Approval for all mobile home park new systems Flood Plain requirements. L2' above established flood elevation to bottom of system �All tanks anchored or 2' above flood elevation TOWN OF QaSB �LEcopy BUILDING &Reviewed ByTown Of Queensbury7per imp i 4„ 0 �N�R:,DENISE A GARTIE { �c...�',z''>':?,• "I - tea:,"':'..�^- + t�WNER:AL N aNNER�LISA di/lILLfA,'RS :•: ;�� mot'.; �� • ';�:�: ;.--, eL,3os ias ri �Fi':LECiNFPAORI,N •'.. _ �.•.. - . .. K SBL:309.�t1:�� 0 FfR? B Olt SBL.309.10�i.72 OYYINER.,MELlSSA FINCH ST.JDHN 309.10-1-75 SEP-0562-2021 E C E 0 V E Warrington, Amanda 44 Luzerne Rd JUL 2 7 2021 Residential Septic Alteration TOWN OF QUEENSBURY BUILDING&CODESLj XY Location-73.670, 43,303 20 40 t