SEP-0855-2021 .... ....... ....
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Permit: :.rm -4
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Permit Fee:$..
7.42-bay:.Road;.04iabnsbu.t.v,.NY'128.04
MW b-i0let Xgueens _U__
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EFT!CDI SP.OSAL::PERMIT.AP.PLl.C-.A-.TION
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Project.:Locations C� �
Tax:Map., .-
C E UVE
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DEC 01 2021
sw.8IDENCEINFORMATION"
TOWN OF QUEENSBURY
BUILDING &CODES
wofbed Lallans Per : =total daily flow Gallons
per.Aay. n G GA�bpgq:.:.�.rin er. Yes�--. N
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:.1580.oro dee '150 Intf...
allod. .. ......
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.1 81:19K: 130' T Yes No'
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000INFORMATIOW,
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p9 .:a: J ` g
si .3 slppV :Flat Rollin
Sol :N*bturis: Sand Loam a he
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*At what Ae
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e t ' i'a I � At:Wh:zitde
rp.c.,,:,,mperv0Us.ma, er
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I un161,p, I
_pPly. Lake.
-1 k C.,
if well or' "t rsup orp .;4n-y-,,5-.eO"**'.�-Y.',$t�'0.0:�bsorp.,t.i
qip� wa...er ionis-,
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'b" """ kedbw�a-
Percolatim-Test ka,te: .-porrninUtep nch::(tg
etombf
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onse d-,origin &/architec
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:-PR.OPOSED..-:SMEM-.:INFORMATION--.
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d error
.
m er or
T�n,k's"i i e: 'loon .,.g�lbn� '(.Min. size.i 000"g"a' llons- -add-250:gpjlons fqr:oat'h
:q
apa/. dt:-tub
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System; o :: lel
:Absorpti 'ph d.'', 2stbh Total len h:..
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Seepage::,pit w/#3, ::st0f)'0: .;Ho.*W::::rh'8f0.-,Y,!�.- ...........
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Alter'..n' p a.t- e System: -B.edor.other type
_:
Hd1di'n T6 h -'-yst"em Total.required capacity?
0tyI
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SeptICA Ocation:
Revised e er,
MIN.
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CQN AGT:INFORI1t1ATIC}N PLEASE PRINTLEGIBLY OR TYPE°, PLEASE;INCL:DE AN:EMAIL i
:•. :A lira t:: i
Names) -�a C.-
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Mailing.Adtlress;.CJ5
Ce{!:Phone: - Land L"ine:. )r1� 9
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Email: r ��, i C_ C�Yn .
:Rrimary:O:wner(s1::
NatTlef . ...... c�c,�.n�
Mail ng:Add:eess :C/S/Z .
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..Cell.Phone::_ ) -._.. . Land°Line::'
Email:
0:"Check if all wont will'be. .erfor ed by property:owner onl
p
:Contrack�r:
:C N ontad a"rh is) In
Contraction.:`Trade:
Mailing..:Address-, C:S/Z:. : .:.:-. —n
Cell Phone:_( } - Land:Line: -r�):
Email: . L o. -P�1. .
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*. :W.ork ers':COMis:doCUM6ntat ®rr.must bt ubMitted With . i$ application'*
A Engineer s
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Name.(s): . _
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Mailing Address: C/S/Z::.. .. . .....
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Cell Rhone *: . ) Land tine: _�. .... :....}....... .. .... .. ......
Ema d: ._. ............ .. .
Contati0erson for Comj�liance<in`r.egards;tio"this prv�eet;. . V
Land Line:: ..:.. . ..:...: ...:..:::
.Cell".Phon'e:': ( _). �......
.-NOTES..1.:Alarm system::and associated:electrical"work must:be::inspected .I a;Town.apptaved e.'ectr.ical
i:rinpeetion:agency;2_.:We Will no longer allow"systehls to be--cover'e.d uh'Vl.such.°t{:m'e as:ari as.-built:p.lan'is
received and approved.The installed system:must match:the.'septic-layout.on:file- .no:exceptiofns. 3.....
built d -pwings:must be submitted.prior to the::insp.ectic n if there has tieeh-,a,tharrge to the:subri•iitted"
pIaRS:;4.:1f -fo.r.:ar�.y,.reason;:the:b.ui[ding;permit'application..is.w:itihdrawn,,3�}°��'-af:tF a feb is re ained.try he
Town of Queensb'Ury.:After 1 yoarfrom the initial application.date,100%af;the.fee.is refiarn d..
Declaration::An:y permit or appr."oval,granted:which as based:upon:or is,granted<in::reliance:upon any.;mater ai
representation or fai{ure to make a material fact'or.circurristance known byor nn behalf of;an:app{icant;.shal) Eie:
yoid. {have.yead the regulations and.:agree.to abide by,these and,all requi.rehlents.vf the Town cif Queenstiiarjr
Sanitary.Sewage:Disposal Ordinance:
RR[NT::NAME;.:: .:• CA1v"
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-...;;:.::;.::..t- . : :. LATE:`:::: <:::::>;>< ::: :'::.:::.
:. ..SIGNATURE. ....... ..
SepticeApplitation. Revised,Decern6er 2020
TOWN OF OUEENSBURY
742 Bay Road, Queensbury, NY. 12804-5902
Septic System Checklist
Plan to scale
�JD 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)kNDII/
4(6All wells on property and ro adjacent r p p y n a J cent properties shown
4wwater 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
iV 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
4seepage pit 150'from well 50'from septic tank
4Seepa9e Pits 37times diameter apart
Septic tank and pump stations over 30 gallons 50'from watercourse or wetland
�clistance.from bottom of trench or system 24"to bedrock or mottling 36"w thin 1000' f Lake George
thin
'L'SLeech field 100 from watercourse or wetland
t ' ' 110'from property line 100'from well 20'from
Foundation
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
All tanks anchored or 2' above flood elevation
Revised 4/15/2021
No I IN NNE NONE ME III
y
sr 5-
DEC 0 7 2021
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