SEP-0889-2021 ..............: -
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� � �
D it Perm :#:.
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i
� ,V ..... DEC 29 20
2 Perrriit.Fee:$. ��.... .... . ..
rY::NY`12B0 aY` oa ueens_u.
I?c:51g=7fi1�8Z5S:'w�+w.gtieeiist�uiy; 4 ��"'
TOWN OF QUEENSBURY Invbie :;# . ........
BUILDING&CODES ^
i Fl
nerio .Zo :' 1' Rev ewed i3
SEPTIC:DISPOSAL RERM1T:aPRUCATIt)N vN Y-Nt ,, �m
Pro'ect;Lvcation! ��rj
1.. (�ca�
is
Tax:Map# ..30 as
RESlD:ENCE IN.FORMATIOM _
Year Built Gallons #of b.edrogms� X:gallons per =total daily flow:
per day.... . bedroom I Garbage.Griner 'Yes; .
_.
1980::or:.older :150jam Irrstalletl?::Icirc(.e'ph
e}..
:19811991 10 "Spat o:r Hot°Tup Yes o
:49920r'6*9 nt 1-0`
Insta.11e ?.{circlearie}
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�.. : :PARCEL_INFQRMATI:UNc: __._ . .
.... . ... .......... ...... .
To .pgraphy:. .Flat Rvll%ng: . SI'o.'Q: :.... l:S1Q ` ;
�..�.»:.... P : . p : . . r o;.... .. p
Still Nature Sand Loam:
Clay ather,.e plaiW
._Gro:unclWater: ......: :..:..:....... .. At.what th..
..... - .
Be ..ro:c Imperviaus:ma#er..il . :At:uirhat deptEi?
po:mestic:Water s,u,pply _ Municipal _Well: _�;Lake
{Ifi Well or'lake tivater:supply from any$".:"t ystem ai sorption:is<
ft.}
. ... . . . ..... . . ............ . ..... .
Percolation Test; Rate:
. .... .. .
per minute:p:er mch {test;tabe.cgmpletetlby a
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...:.:hcens+�d:engineer architect}
... . .......... ... .......... .... .. .
.PROPOSED SYSTEM:INE:ORMATIQN.
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Tank:siie a. K :'rriin. size.1,000. allons; add 25o,gaIlons for eae :gat bage cylinder or
g. { g
spa/ljbt tub e,
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System; ° Absorption'#field:w #Z stone Total length. ft . EackiTrench.'
Seepage:Pit.w/#3 stone Hovv rrr:anj ;. _.. :;saz .
Alternative Sjrstofn Red or othertype_: :.
H:oliing Tonle System Total:requir;ed capacity: :tan:k::size ... .
#-of tanks
Septic application: Revised d becemper-1020:
CONTACT .IN17ORMATION- PLEAS.E.PRINT LEGIBLY 09 TyplE, PLEASE WCWciE.:�=::N IL
A licant:
Mailing Address, C/$/ :
Cell Phone: {. � E tnd Line _i1F; '67g4"?r
n
® ;PCiman..®wner S :Narrme(s .;: - r�. Lei=. �:,.. . � '�c1 bail r
Mailing Address, C/vz: 3 - ...-
Cell Phone:=( Lar i lno {,
Ernall
CI Check if all,work will be Oerformed by PrOoerty oWoer
Contractor. [ ,s
Contact Name(s):
COntractbr'Trade: c t!� k r
1
Cell Phone:_( Land Line:.
-- -- ---- ---- ---------- ..
.... .
Email: - _ _
**W rke torf p docuibent tl®n.must b'e submitted eth.th�s_.a���ii����
ngineert S):
Mailing Address, C/S/2:
Cell Phone-f_( } Land
Lin-{.. } -
Contact Person for Compliance iti;-regards to this project:
Cell Phone: ( Land Lime: _
NOM: 1.Alarm system and associated electrical work.must be:•inspected by.a TOP opproved electrical
inspection agency;2. we will no longer allow systems to be covered u as-built plan is
received-and approved.The installed system-must m.6tch tho'septic-layout•ort:: Ce:=nc :exceptions. 3.As-
built drawings-must be submitted prior tothe inspection;,if them has 1ae rr;a l :ge:to kie submitted
plaos:4.if, for:any reason;the building.perrrrit applitration isribdert;� �li Theis retained.by the
Town Qf Queensbury. Af€er I year from the initial applicativft date,�Gl� of.'t ig Js retaii�e>�..
Declaration:Any permit or approval granted W- hich is-based-opton or.is:grgl b� n—.-.r! laic e p tr_att r:i iazeciai
representation or failure•to make a material fact•or.circumstanee•-Kho�vn�by'or onibOhglf*.6f:an:abol ear€t Shall�be:
void. l have read the regulations and agree to abide by these and:afl:requirements:cif the TflW...`f ie: i s aui y
Sanitary Sewage Disposal Gedinance.
PRINT NLlN1E:- .. u uc-v 1 . ------------
SIGNATURE:
Septic Application Rer ised.becember 2023
s• :'n
TOWN 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)
N All wells on property and adjacent properties shown MU0,�\,C����--
YVl/ater 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
1Septic tank and pump stations 10'from foundation 50'from any well/lake/wetland 10'from any waterline
YSeptic tank to foundation crawl space/ lab on grade grade in crawl space must be above top of septic tank
for 0;Separation required (field verifica ion 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
_kSeepage 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
distance from bottom of.trench or syst 24" edrock or mottling 36"within 1000'of Lake George
Leech-field 100'from watercourse or wetland
—P—Toe of mound or bottom of retaining wall 10'from property line 100'from well 20'from
Foundation CAD
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
1" All tanks anchored or 2' above flood elevation
Revised 4/15/2021
t W
MEN M
No