SEP-0479-2021 s.
SEPTIC DISPOSAL PERMIT Office Use Oniv, C
APPLICATION Permit#: q� 1' — 2 2, 1
Town of(ttteembury O
i
Permit Fee:$ v
Invoice#:
742 Bay Road,Queensbury,NY 12804
P:518461-8256 mvivygueensburv.neC Septic Variance? Y M
Flood Zone? Y i>
I
Wetlands? Y Reviewed By:
Project Location: 3239 State Route 9L
Tax Map#: 239.18-1=49
RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms X gallons per =total daily flow
per day bedroom Garbage Grinder Yes No
1980 or older 150 Installed? (choose one) ❑ [�
1981-1991 130 Spa or Hot Tub Yes No
1992-Present. 110 4 Installed? (choose one) El [0
110 440
PARCEL INFORMATION:
Topography 91 Flat Rolling ❑Steep Slope %Slope
Soil Nature Sand Loam ❑ Clay ❑ Other, explain:
Groundwater At what depth? 18'
Bedrock/Impervious material At what depth?,-greater than 39"
Domestic Water Supply ❑ Municipal Well ❑Lake
(if well or lake, water supply from any septic system absorption is
101 ft.j
Percolation Test Rate: 1-5 min per minute per inch (test to be completed by a
licensed engineer/architect)
PROPOSED SYSTEM INFORMATION:
Tank size 1.256 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 _20o ft.; Each Trench so ft.
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 April 2021
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
y
• Applicant:
Name(s): Steve Dempsey
Mailing Address, C/S/Z: 3239'State Route 9L Lake George, NY 12845
Cell Phone: Land Line: 917-208-5609
Email:
• Primary Owner(s):
Name(s): same as applicant
Mailing Address,C/S/Z:
Cell Phone: Land Line:
Email:
❑ Check if all work will be performed by property owner only
• Contractor:
Contact Name(s): ' Paul Bromley&Sons
Contractor Trade: Excavation/Installation
Mailing Address,C/S/Z:
Cell Phone: 518-470-2050.(Tom Bromlev) Land Line:
Email:
*.*Workers' Comp documentation must be submitted with this application**
Ensineer(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: thutchins6hutchinsengineeringcom
Contact Person for Compliance in regards to this project: Steve Dempsey
Cell Phone: Land Line: 917-208-5609
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. I have read the regulations and agree to abide by these and all requirements of the Town of Queensbury
Sanitary Sewage Disposal Ordinance.
PRINT NAME: G.TV3mas Hutchins A nt
SIGNATURE: C,%t; , DATE: 6/30/21
Septic Application Revised April 2621
TOWN OF QUEENSBURY
742 Bay Road, Queensbury, NY. 12804-5902
Septic System Checklist
Plan to scale
.u?Received Deep hole perc test results from engineer/Architect if applicable(Town Approved Engineers and
rchitects;June 30 to April 15 Town Engineer for unapproved Engineers and Architects)
�AII wells on property and adjacent properties shown
U-&S water line shown Municipal or well 10'separation to any part of system
f/S Setback to property lines show 10'or more for any part of system
ISeptic tank and pump stations 10'from foundation 50'from any well/lake/wetland 10'from any waterline
T— -_W
&/l%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
��eech Field 20'from foundation 100'from any well 10'from water line
4seepage pit 150'from well 50'from septic tank
W-�—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 mottlQiwithin 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
Provide Engineer/Architect stamp for bed or design systems
AJ Department of Health Approval for all mobile home park new systems Flood Plain requirements
above established flood elevation to bottom of system
All tanks anchored or 2' above flood elevation