SEP-0613-2021 Office Use only
Permit#:__ 20V
�S}f'lR ti3a CfSat>11f}= Permit Fee:
742 Say Road,Queensbury;NY 12804
P;si8-761-82s6 www.clucensbumnet Invoice#: 40e1a
�FI od Zone? Y N Reviewed B '
SEPTIC DISPOSAL PERMIT APPLICATION uv
Project Location:
Q � E
Tax Map #: 0 J • ��
2021
TOWN OF QUEENS13URY
RESIDENCE INFORMATION: OFF
Year Built. Gallons #of bedrooms: X gallons per =total daily flow
per day bedroom Garbage Grinder Yes No
1980.orolder 150 Installed? (circle,ane)
1981-1991 130 Spa or Hot Tub Yes No
Installed? (circle one)
1992-Present 110
PARCEL INFORMATION: _
Topography Flat Rolling Steep Slope I Slope
Soil.Nature Sand Loam Clay Other, explain:
Groundwater At what depth?
Bedrock/Impervious material At what depth?
Domestic Water Supply _ Municipal Well Lake
(if well or lake, water supply from any septic system absorption is ;
Percolation Test Rate: per minute per inch (test to be completed by
licensed engineer/architect)
PROPOSED SYSTEM INFORMATION:
Tank size n gallons (min. size 1,000 gallons, add 250 gallons for each garbage cylinder or
spa/hot tub
System Absorption field w/#2 stone Total length ft:; Each Trench So fit.
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): �-
Mailing Address C/S/
Cell Phone: - Land Line: _( }
Email: S ,
• Primary Owners :
Name(s): -��, v 6
Mailing Address, C/S/Z: V s W-
Cell Phone: 0 Land Line: _( j
Email:
❑ Check if all work will be performed by property owner only
• Contractor: —�
Contact Name(s): J
Contractor Trade: Ire '°
Mailing Address; f n (A _
Cell Phone _( } — Land Line: _( } ..
Email:
"Workers' Comp,documentation must be submitted with this application"
• Eneineer(s):
Name(s):
Mailing Address, C/S/Z:
Cell Phone:_( } Land Line:
Email:
Contact Person for Compliance in regards to this project:
Cell Phone: { } Land Line:
Email:
NOTES:.1. Alarm system and associated electrical work must be inspected by a Town approved electrical
inspection agency; 1 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 Dis osaI Ordinance.
PRINT NAME:
SIGNATURE: . DATE:
Septic Application Revised December 2020
TOWN OF OUEENSBURY
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 shown
Water line shown Municipal or well 10'separation to any part of system
Setback 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
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 2 o bedrock or mottling 36"within 1000'of Lake George
YLeech field 100'from watercourse or wetland
Toe of mound or bottom of retaining wall 10'from property line 100'from well 20' from-
Foundation <:� Z) 0\) �-�e�� �t�—
Provide Engineer/Architect stamp for bed or design systems
Department of Health Approval for all mobile home park new systems Flood Plain requirements
12' above established flood elevation to bottom of system
All tanks anchored or 2' above flood elevation
Revised 4/15/2021
'Town Of QueensburyInteractive Mapper
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