Application SEPTIC DISPOSAL PERMIT office UseOnnlly
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APPLICATION Permit#:�7e� —Ob��- 2021
"ro"nr(bCemAury 8�Permit Fee:$
Invoice#: 412�
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 ww_�.queensbur+;r!e= Septic Variance? Y
Flood Zone? Y N
Wetlands? Y N Reviewed
Project Location: a �; 78 15
Tax Map #: SOR, 1 4) - :�—
RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms: X gallons per =total daily flow
per day bedroom Garbage Grinder Yes tNo
1980orolder 150 Installed? (choose one)1981-1991 130 Spa or Hot Tub Yes
1992-Present 110 Installed? (choose one) ❑
PARCEL INFORMATION:
Topography Flat Rolling ❑ Steep Slope % Slope
Soil Nature ® Sand ❑ Loam ❑ Clay ❑ Other, explain:
Groundwater At what depth?
Bedrock/Impervious material At what depth?
Domestic Water Supply X Municipal ❑ Well ❑Lake
(if well or lake, water supply from any septic system absorption is
ft.)
Percolation Test Rate: 4`,2 per minute per inch (test to be completed by a
licensed engineer/architect)
PROPOSED SYSTEM INFORMATION:
Tank size Jj OCOgallons (min. size 1,000 gallons, add 250 gallons for each garbage cylinder or
spa/hot tub °y
System Absorption field w4okitar4 Total length Jto ft.; Each Trench ft.
Seepage Pit w/#3 stone How many: ; Size:
Alternative System Bed or other type*-"" . I
Holding Tank System Total required r0a A', ; Unksize ;
# of tanks
(; AUG _nu!
�"r r
Septic Application Revised April 2021
j CONTACT IN�.FORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
li• (
Name s): r D/!d._/MS k/l a
Mailing Address, C/S/Z: �Fss {G•S�✓i CPu �j�, ��
Cell Phon : {�;1 Z�z 6767 Land Line: Vie:
Email: e1j,7JV f-i'r $ - C;15r->+
• Prim n s :
Name(s): u i c5 �1
Mailing Address, C/S/Z: , cl + (al✓cx'-+�5�� �
Cell Pho Land Line_:�
Email: a cry, �Pr'>�T•�,�tv,n
❑ Check if all work will be performed by property owner only
• Contractor:
Contact Name(s):
Contractor Trade: S
ct
Mailing Address, C/S/Z: ' e.CO fG'
Cell Pho e: /• =Z Land Line: f�- -1t7`
Email: ez. c{�sSre�d Cl�v>7
"Workers' Comp documentation must be submitted with this application"
• En i rs : r
Name(s): KvCL.%
Mailing Addre s, C/S/Z:7 5L d. �:"4�S` � t -2,06
Cell Phone: 5 - ,9> 7 -a0 cU Land Line:
Email: Ir'v r e nG r,rri ✓5 r
Contact Person for Compliance in regards to this project: ecc ri ✓ d,r;
Cell Phone: i7,4767 iLand Line: ! f0
Email: �Pi_ Pyc v���'Ti
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 Dispo I Ordinar�c
PRINT NAME: /
SIGNATURE: DATE:
septic AppllWl . Revised April 2021
s . TOWN OF QUEENSBURY
742 Bay Road, Queensbury, NY. 12804-5902
Septic System Checklist
Plan to scale
Received Deep hole pert 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 M ov-�\ C ��
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
2
Septic tank and pump stations from foundation 50'from any well/lake/wetland 10'from any waterline
M VW'ME
Septic tank to foundation crawl space/slab on grade,grade in crawl space must be above top of septic tank
for0',Separation required (field verification required)
Septic tank size I d for number of bedrooms and add 250 gals for Jacuzzi tubs/garbage grinder each
Leech Field 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 24" ock or mottling 36" within 1000' of Lake George
Leech field 100'from watercourse or wetland
-LToe of mound or bottom of retaining wall 10' from property line 100' from well 20' from
Foundation L o I3JEt7
Provide Engineer/Architect stamp for bed or design systems
Department of Health Approval for all mobile home park new systems Flood Plain requirements
�\2' above established flood elevation to bottom of system
N All tanks anchored or 2' above flood elevation
Revised 4/15/2021