RC-0367-2021 Office Use Only
MANUFACTURED HOME
/ Permit#: �'
PERMIT APPLICATION Q . 00
----ti1 Permit Fee:$ Z
Town ofQueensbury
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.gueensbury.net Rec Fee:$
Invoice#: ��
Flood Zone? Y N Reviewed By:�
Project Location: LWtG [(,G _ aUg:27.0t7 �d�f
Tax Map ID#: ZI(o
Name of Park (if applicable): Ir�
PROJECT INFORMATION:
1. Proposed Date of Placement:
2. Approximate Value of Home:$
3. Is the home NEW or a REPLACEMENT ?
4. Single-wide or Double-wide F Size: `6 i ft.X qQQo! ft.= total square feet
5. Foundation support(choose one): Size Depth
Piers:
�i Slab:
6. Is the home being placed on a private lot? No Yes**
(**if yes,you must provide stamped engineered drawings of the permanent foundation plan)
7. Total#of rooms(exclude bathrooms): ;#of bedrooms:— 1)1_ ;#of bathrooms:
8. Additional heat source? No Yes Choose one, if yes: gas fp_ woodstove_ wood fp
9. Are there any other/existing buildings on the property? No Yes ; Explain:
10. What is the water source? PUBLIC_)L PRIVATE WELL
11. What type of wastewater system is on the parcel? SEWER PRIVATE SEPTIC
12.._Do you need aseptic permit application? No Yes
MANUFACTURED HOME INFORMATION:
(INFORMATION FOUND ON THE PLATE OR STICKER LOCATED IN THE HOME):
Insignia serial #:T477 I
Name of Manufacturer:
Place approval#:
Model or component designation (Ne Home Only): t00
Date of manufacture: c�-z. "
Manufactured Home Application Revised January 2021
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REQUIREMENTS FOR SUBMITTAL:
1. Completed Manufactured Home permit application
THREE (3) COPIES OF THE FOLLOWING:
2. Structural drawings,which include:
a. Floor plan
b. Foundation plan (see 2015 IRC Appendix E Section AE502:foundation systems)
c. If the home is being placed on a private parcel (not in a manufactured home park or designated
zone),you MUST provide stamped engineered drawings of the permanent foundation plan.
3. Plot plan, using a survey map if possible,which includes:
a. Drawn to scale (i.e. 1 inch = 30 feet)
b. Indicate proposed location,with setbacks
c. Include all structures on the property
d. Include location of water supply(well or water lines)
e. Include location &configuration of septic system or sewer line
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ADDITIONAL SUBMITTAL INFORMATION:
1. Installer Warranty seal must be provided prior to issuing Certificate of Occupancy.
2. Any changes to the approved plans prior to or during construction will require the submittal of
amended plans, additional reviews and re-approval.
3. 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.
4. Workers' Comp insurance information for all contractors involved—REQUIRED, EVEN FOR SOLE
PROPRIETORS
DECLARATION:
I swear that,to the best of my knowledge and belief,the statements contained in this application,together with the
plans and specifications submitted,are a true and complete statement of all proposed work to be done on the described
premises;and,that all provisions of the NYS Building Code,the Zoning Ordinance and all other laws pertaining to the
proposed work shall be complied with,whether specified or not,and that such work is authorized by the owner.
I have read and agree to the above:
�1 I
PRINT NAME:
SIGNATURE: DATE: /7
Manufactured Home Application Revised January 2021
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s):
Mailing Address, C/S/Z:
Cell Phone:_) Land Line: � )
Email:
• Primary Owner(s):
Name(s):
Mailing Address, C/S/Z:
Cell Phone: Land Line: _L )
Email:
❑ Check if all work will be performed by the property owner only
• Contractor(s): (List all additional contractors on the back of this form)
Contact Name(s): i,I e,I i5��-4-
Contractor Trade: hWu 4� -4&r 6 24,
Mailing Address, C/S/Z: 2-ioo
Cell Phone: ( 519' 42,4 cj�CX' Land Line: ( S18" )
Email:
"Workers' Comp documentation must be submitted with this application"
Contact Person for Compliance in regards to this project: cr
Cell Phone: �_) Land Line: ) g� s G c8i
Email: y- Cel,
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Manufactured Home Application Revised January 2021
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Office Use Only
Permit#: k, ��' ?AZi
Torn of(Leensbun
Permit Fee:$
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.gueensburV.net Invoice#:
Flood Zone? Y N Reviewed By:
SEPTIC DISPOSAL PERMIT APPLICATION
Project Location:
Tax Map #:
RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms: X gallons per =total daily flow
per day bedroom Garbage Grinder Yes t o
1980 or older 150 Installed? (circle one)
1981-1991 130 Spa or Hot Tub Yes ffNo,)
1992-Present 110 Installed? (circle one)
PARCEL INFORMATION:
Topography J,- 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 -/funicipal _Well _ Lake
(if well or lake, water supply from any septic system absorption is
Percolation Test Rate: /—S� per minute per inch (test to be completed by a
licensed engineer/architect)
PROPOSED SYSTEM INFORMATION:
Tank size oi% 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 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 December 2020
f.
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s):
Mailing Address, C/S/Z:
Cell Phone:_( ) Land Line: _( )
Email:
Primary Owner(s):
Name(s):�1r"" 0 C)"�
Mailing Address, C/S/Z: �� �> �C-� - d , ��� �� fC) �60
14
Cell Phone:_( S I YS Land Line: _( ) ILL//
Email: �A
❑ Check if all work will be performed by property owner only
• Contractor:
Contact Name(s): ' �
Contractor Trade:
Mailing Address, C/S/Z: Z
Cell Phone: 75E - S 760 Land Line: _(s��� ) 779z — 7c:26-f-,7
Email: 1'0lol 10 1-7
** orkers' Comp documentation must be submitted with this application"
• Engineer(s)•
Name(s):
Mailing Address, C/S/Z:
Cell Phone:_( ) Land Line: _( )
Email:
Contact Person for Compliance in regards to this project: (�O(A2f
Cell Phone: (S Ir Land Line:
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 Dispo Ordinance.
PRINT NAME: 0/
SIGNATURE: DATE:(z — 2�
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Septic Application Revised December 2020
TOWW OF QUEENSBURY
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 kvV
lAwater line shown Municipal or well 10'separation to any part of system
yk Setback to property lines show 10'or more for any part of system
19 Septic tank and pump stations 10'from foundation 50'from any well/lake/wetland 10'from any waterline
)V ASeptic 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)
14 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
NIA distance from bottom of trench or system 24"to bedrock or mottling 36"within 1000' of Lake George
Leech field 100'from watercourse or wetland -
MkToe of mound or bottom of retaining wall 10'from property line 100'from well 20'from
Foundation
N' Provide Engineer/Architect stamp for bed or design systems
Alldc Department of Health Approval for all mobile home park new systems Flood Plain requirements
Art rk VIACiZ_
2'above established flood elevation to bottom of system
No All tanks anchored or 2' above flood elevation
GENTER PROM
SERVICES
73 Sheridan Street, Glens Falls, NY 12801
Phone-518-796-2515
September 22, 2021
Project_ #355
George Drellos
Sanitary Sewer Service
Queensbury;NY 12804
Re: Proposed Replacement Septic
33 Sweet Road, Queensbury,NY
Dear George:
At your request, we have reviewed your proposed replacement septic system design of the new
3-bedroom modular home at 33 Sweet Road in Queensbury.
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 330 GPD and a percolation rate of
1 to 5 minutes, you will need a minimum of 367 sf of absorption area. We recommend using 20
ft wide by 25 ft long absorption bed with 4 — 20 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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