SEP-0617-2021 Office Use Only
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SEPTIC DISPOSAL PERMIT APPLICATION Permit#: ��Ol�l
Permit Fee:$� �Invoice#:
Town of f ,77 ,y
Septic Variance? ✓ Yes No
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.ci6ee6sbury.net•.
Tax Map ID#: 297.17-1-83
Project Location: 30 Meadow Drive
Applicant:
Name(s): Phyllis Hess (Henry Hess-deceased)
Mailing Address, C/S/Z: 30 Meadow Drive Queensbury, NY. 12804
Cell Phone:_(- . ) Land Line: _( 518 ) 792-2430
Email: blessedyankee@gmail.com
• Primary Owner(s):
Name(s): same as applicants
Mailing Address, C/S/Z:
Cell Phone:_( ) Land Line: _( )
Email:
❑ Check if all work will be performed by homeowner only
• Contractor: Workers' Comp documentation must be submitted with this application
Contact Name(s); -Ellsworth and Son Excavating
Contractor Trade: Excavating/Septic Installation
Mailing Address, C/S/Z: ;
Cell Phone:_( 518 )`361-1993 Land Line: _(518 ) 792-9246
Email: digging@ellsworthexcavating.com
• Engineer(s):
Name(s): Hutchins Engineering PLLC
Mailing Address, C/S/Z: 169 Haviland Road Queensbury, NY 12804
Cell Phone: _( ) Land Line: '(518 ) 745-0307
Email: tutchins@hutchinsengineering.com
Contact Person for Building & Code Compliance: Ruben Ellsworth
Cell Phone: J 518 ) 361-1993 Land Line: _( )
Email:
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Septic Application Revised February 2019
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RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms: X gallons per total daily flow
perclay bedroom Garbage Grinder Yes o
t III
1980 or older 150 Installed? (circle one)
k Spa or Hot Tub Yes
1981-1991
Installe
Ed? (circle one)
PARCEL INFORMATION:
Topography Flat Rolling Steep Slope %Slope
Soil Nature V Sand Loam Clay other(explain:
Groundwater At what depth? no evidence to 36"
Bedrock/impervious material At what depth? 36"
Domestic Water Supply / Municipal _Well (if well,water supply from any septic system absorption is_ft.)'
Percolation Test Rate: 6-7 per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size 1,250 gallons (min. size 1,000 gallons,add 250 gallons for each garbage cylinder or spa/hot tub
System Absorption field with#2 stone Total length 220 ft.; Each Trench 55 ft.
Seepage Pit with#3 stone How many: Size:
Alternative System Bed or other type:
Holding Tank System Total required capacity? tank size #of tanks
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.
Any permit or approval granted which is based uponoris granted in reliance upon any nnateria|
representation mr failure tornakearnateria|fact orcircunnstance known byoron behalf ofan applicant, shall be
void. I have read the regulations and agree to abide by these and all requireme n1ts of the Town of Queensbury
Sanitary Sewage Disposal Ordinance.
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PRINT NAME: DATE:
SIGNATURE: DATE:
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Septic Application = � Revised pebmoryumy
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TOWN OF OUEENSBURY
742 Bay Road, Queensbury, NY. 12804-5902
Septic System Checklist
��Plan to scale
qIALReceived 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)
aAll wells on property and adjacent properties shown .fA L
J'eA 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
4k—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
Pl*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 system 24"to bedrock or mottling 36"within 1000' of Lake George
I Leech field 100'from watercourse or wetland
*1 foe of mound or bottom of retaining wall 10'from property line 100'from well 20'from
Foundation
�--('-S—Provicle Engineer/Architect stamp for bed or design systems
4-Department of Health Approval for all mobile home park new systems Flood Plain requirements
f'J6 2' above established flood elevation to bottom of system
N(6 All tanks anchored or 2' above flood elevation
Revised 4/15/2021