SEP-0769-2021 SEPTIC DISPOSAL PERMIT office use only
APPL �n .. Permit#: _
Town of Oycensbory D IJ ` �p
rmit Fee:$
®CT 18 2021 voice#:
742 Bay Road,Queensbury,IVY 12904
P:515-761-8256 L3rvnrv.ctueenSbur��.net TOWN OF BUIL QUEBIVSBURY lood Zone? Y N� Reviewed By.
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Project Location: 654 LUZERNE ROAD
Tax Map#: 308.5-1-32
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 or►e)' X
19>31-1991 130 Spa-or HotTtib. Yes' No
1992-Present 110, 2 .110 1220__
--Installed? (choose one} X
PARCEUNFORMATION:
Topography Flat Rolling Steep Slope % Slope
Soil Nature VSand Loam Clay Other, explain: -
Groundwater At what depth? GREATER THAN 6 FT
Bedrock/impervious material At:What depth? GREATER THAN 6 FT.
Domestic Water Supply Municipal Well Lake-
(if well or lake, water supply from any septic system absorption-is
Percolation Test Rate: 1-5MIN per minute'.per inch (test.to be'c6m,pleted by a
licensed englneer/architect)
PROPOSED SYSTEM"INFORMATION::
Tank size l000 gallons (min. size 1,000 gallons, add 250 gallons for each garbage cylinder or
spa/hot tub NEW 1000 GAL CONCRETE
System -Absorption field w/#2-stone Total length* ft.; Each Trench -- ft.
, ft.
Seepage Pit vii/#3 stone How many: ;!Size:
Alternative System Bed or other type:20 FT X 20 FT
Holding Tank System Total required capacity? ; tank size ;
#of tanks -
septic Application Revised January 2021
CONTACT INFORMATION: PLEASE.PRINT LEGIBLY OR TYPE,.PLEASE INCLUDE AN EMAIL
• Applicant:.
Name(s): FAITH BELISIE
Mailing Address, C/S/Z: 9 HEINRICK CIRCLE:QUEENSBURY,NY 12804
Cell Phone: Land Line:
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):SANITARY.SEWER SERVICES
Contractor Trade:
Mailing Address, C/S/Z:LUZERNE RD, QUEENSBURY
Cell Phone: Land Line:518-796-3760
Email:
"Workers" Comp documentation must he submitted with this application"
® Enaineer(s):
Name(s):CENTER PROJECT SERVICES
Mailing Address, C/S/Z:73 SHERIDAN STREET, GLENS FALLS NY 12801
Cell Phone: Land Line:
Email:
Contact Person for Compliance in regards to this project: GEORGE DRELLOS _
Cell Phone: Land Line: 518-796-3760 ..
Email:
NOTES: 1. Alarm system and associated electrical work must be inspected by a Town-approved electrical
inspection agency; 2. We'wili 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 O nce.
PRINT NAME:GEORG RE sz-- '
SIGNATURE: DATE:C./ 10-� �—
f
Septic Application Revised January 2021
TOWN OF OUEENSBURY
742 Bay Road, Queens bury, NY. 12804-5902
Septic System Checklist
doPlan 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)
AAll 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
ZSeptic 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)
Ia— 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
AgSeepage pit 150'from well 50'from septic tank
&SSeepage Pits 3-times diameter apart
Septic tank and pump stations over 30 gallons 50'from watercourse or wetland
distance from bottom of trench or system4"to bedrock or mottling 36"within 1000' of Lake George
Leech field 100'from watercourse or wetland
oe of mound or bottom of retaining wall 10'from property line 100'from well 20'from
Foundation
Vprovide Engineer/Architect stamp for bed or design systems —�
Department of Health Approval for all mobile home park new systems Flood Plain requirements
P 10 2' above established flood elevation to bottom of system
WAII tanks anchored or 2' above flood elevation
Revised 4/15/2021
TOWN OF QUEENSBURY
BUILDING & CODES DEPT.
Reviewed ye
Date:
-F
TOWN OF QUEENSBURY
BUILDING DEPARTMENT
K Rased on our limited examination-compliance
�ith our comments shall not be construed as
ihdicating the plans and specifications are in
fill compliance with the Building Codes of
New York State.
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.308.5-1-32 SEP-0769-2021
Belisle, Faith
654 Luzerne Rd
Residential Septic Alteration
a ;
WATER PROJEW
SERVICES
73 Sheridan Street, Glens Falls,NY 12801
Phone-518-796-2515
October 2, 2021
Project# 357
George Drellos ------LEE-
Sanitary Sewer Service
Queensbury,NY 12804 Re: Proposed Replacement Septic 021
654 Luzerne Road, Queensbury,NY ODESRY
Dear George:
At your request, we have reviewed your proposed replacement septic system design of the
existing 2-bedroom house at 654 Luzerne Road in Queensbury. As per our conversation the
residence has an existing failed septic system.
We have reviewed the proposed replacement septic system design and we agree that a standard
absorption bed is acceptable. Based upon a design flow rate of 220 GPD and a percolation rate of
1 to 5 minutes, you will need a minimum of 245 sf of absorption area. We recommend using 20
ft wide by 20 ft long absorption bed with 4 — 15 ft long laterals. The absorption system can be
constructed with the new 1,000-gallon septic tank, new distribution box, and 4-inch diameter
perforated pipe and stone.
Please feel free to contact me at 796-2515 if you have any questions and that you for your
assistance with this request.
Sincerely,
Thomas R. Center Jr, P.E.
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TOWN OF QUIECNSBURY
BUILDING&CODES