SEP-0119-2022 office Usebnly
_. .
Permit
ii nti.wnt 4ii�tiitahair� Permit Fee:$. .6 F
742 BayRoad,Qucbmbury,_NY'12804,
P;:518-Z61=8t56 tiutn+u�;pueensl�iar. .riet
----� -- Invoice.#:
Fiood.2one? Y Rv ewsd:Bj,
SEPTIC;DISPOSAL PERMIT APPLICATION
Projec#Location: 1Z�o Q 1 - JC ! J
1` y�
Tax:Ma . #: .
p 2 �
rowNQUEE
BURY
_. BUILDING L_,_,ODES
RESIDENCEINFQRMATION: _ -----�
Year,quilt '.:Gallons #of bedrooms: X'gallons per . =total dai€y flow
per day bedroom
Garbage,:Grirscl:e.r. Yes �po
t letl (circl.e;cine}1980 or.older 150
1
1391�1991; �0 Spa ar Hot Tub: Yes o
....... .. ....
1992-present: .110 irtstakled?'.:(efrcleane)
PARCEL INFORMATION:
— ... ............
Topography Flat Rolling- SteepSlope °lo Slope
Soi Nature Sand . .Loam: .Clay Other;:, explain:
G.rou.nwater At what depth?
BedrockJlmpervi:ous.materi:al. At what depth?
�.
Domestic Water'Supply Municipal _well: ':Lake_
0 well or lake, water supply from any septic system absorption:is;:
ft.)
Percolation Test; Rate: per minute per inch iate'st;to.b'colmipleted.by a
. ........ ... ......
_I.licensed:engineer/architect'}
P:ROP;OSED.SY'STEM::IN FORMATION:
g. g +g. g : Y
Tank O. al :ons (min. size 1,OOD.gallons,add 25Q,gallons for;each: arba e::c _linger or
spa ;hot.tub
:System Absorption field w #2 stone Total length #t., Each:.T.r.*'�n
'.6h:' :.. ................. ft,
--- — -.. ...........
Seepage:Pit w/.#3 stone How many:: Size; .-...
:Alternative System. Bed or other typ;v.:l�At&.�, - 3-- - CA eza�
Holding Tank System Total required'capacity? tank size
# of tanks
Sepcir.kppljcat€an Revised December2020
i .
::: CONTACT INFORMATI:OM PLEASE PRINT LEGIBLY-OR TYPE,:PLEASE:IN.CLU.E AN EMAIL
• A3011canto.
Mailing Address,,C/S/Z: - • ,
...Cell Phone::_( ) _.... . . Land Line: _( _)
Ema'i
•: . Pr thary..Owner s
Name(s): ,
Mailing Address;C/S/Z o"
Cel[Phone:_( ) land Line: (5.
Email::
O Check if all work;Will be.performed:by property.owner:only
V. iontractor::
Contact:Nar0 0): ��
Contractor.Trade: a rMae
Malling.Addre s;:C
Cell Phone:__( ) Land.�ine:::
Email:
**Workers' Comp do�cumentato:n must bo submiter :with: his_application' *
:. En ineer. SI..
Narno(s): : .. ...... .... .. ... .
Mailing Address;:C/$/Z:. ...... ..... _.
....
Cell Phone: Land Llne:_( } _( )Email: . _.... .
Conta:c.t:Person.for Compliance'in'r..egards.to:this project: � -
cell Phone: c-: 1-
Land Line: ). . . : :: :
Email
NOTES*. 1_. Alarm:system:and, associated.electrical work:must-be inspected by:o Town.approved electrical
inspection::agency 2..We viiill no longer allow . ..-b-s.t6 be covered until sucks 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 chan the ge to: submitted
plans. 4. if, for any reason;the building permit application is wrthd:yawn, 30°l of:tl e fee:is retatned:ley the
Town of:Queensbury. After 1 year from the initial ap'plicatiori.date, 100N.of the fee:is retained.
.
Yp p
Declaration::An ermit:or approVal,gr.anted which is based upon ls.granted in::..r ance..0 on an.y matena
representation or fail Ure to inake :material'fact or.circumstance ltnown by or:on:behalf:b :an,;appiicaRf;Shall be
void':! h;ave read:th a regulations and:aigree to abide by these and�all requirements of the Town'af Queer sbury
Sanitary,.Sew age:Disposal Ordinance._
PRINT..NAME: Y ,..
.
SIGNATURE..: ,.:
DATE::�Calf
Septic Application Rev'iwd:December 2620
TOWN OF QUEENSBURY
742 Bay Road, Queensbury, IVY. 12804-5902
Septic System Checklist
(J� Plan to scale
nl 0 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 Pali'c�
Water line shown Municipal or well 10'separation to any part of system
�`getback 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
f4septic 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)
�__Oseptic tank sized for number of bedrooms and add 250 gals for Jacuzzi tubs/garbage grinder each
�j-C Aeech Field 20' from foundation 100'from any well 10'from water line
Seepage pit 150'from well 50'from septic tank
I') 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 mottlin 36"withi 1000' of Lakq, George
eech field 100'from watercourse or wetland
1✓�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
!�O Department of Health Approval for all mobile home park new systems Flood Plain requirements
Nd 2' above established flood elevation to bottom of system
All tanks anchored or 2' above flood elevation
Revised 4/15/2021
�—I I I I I I I I—I I I I I I I I I I I I I I I—I I_ I I I I I I I I
n n_ nn l F L _ -� n
Alov- _n Ro - h-1 I I-
n Y n n! --
-- Tovur�-c��F - �i��s B- R
-nl I .. I I `� ten_
T_U_l1�!U=^l CEP-- — = — — RLVi W�d �
t< ttl I 1 n
IBUILDI�!, D PAR ENT ®c�lGI:-
-Of__Ou i�rif
indi 31. omr e 3 ron ``' qF
nth sha I not be c nst _d t�s�t
1 3tcLi,—the-•Pap 3 —S E L,i�c.-Cn;
full om liana wi h the 8t it Iio
I -
- n I I
- -- _n
__nnn_ n_ � n
I- _ _ Tn_ 1 I�� ��n_ _ n
N AR
2-2
Its� �o � I� I-n I -n _ I_ nn_ n_ 1
� I I I I I III
n n�nnm-n I Inn m
I- 296.13-1-27 SEP-0119-2022 �____�
Phillips, Cassius
126 Montray Rd 1 1 �77
Residential Septic Alteration
lb �^
n-.nn ---1-I- n-n �Inl
-1 n-- , -��
n l l !n l n- Innn nnn n-nn n n I n-
em
i � ��
C!
ijl