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permit##: P_ O 0*-2 2Z
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Permit Fee:$ 5"
742 6ay:Rogd..CZueon:o dry,.NY:12804:
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SEPTIC DISPOSAL PEUMIT APPLICATION 16A&Y-)�
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Project Location � t
Tax.Map#:
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RESIDENCE.:INFO RIVIATIOIW:
Year Built Gallons #af:lie'droomsc ii`allots per 1 =total daily flow -
per:day bedroom Garbage Grinder. es. Np
1980.or:older 150 instalfecl?.:.tcirr=le'cirte}
1981-1.991: 13.(l Spa;or Hot Tiab Yes. No
1 ,Installed? (elrcle arts)
1992-P:rsent: 110 _ . . .. 11�.. _... ...
PARCE
L:INFORtVIATIOW
,.Topography Flat Rolling .:SteeV ope °!a:Slope.
:Soil Nature Sand Loam Cfay Q:ther, exp1 it <:
Groundwater: At:what depth?
:Bec)rockJfmpervious;materr:al.. :At What depth?
omestie Water Supply � Municipal �Well hake
{if well or lake, water;supply.frorn ariy septic system absorptinr�:is
ft.)
Percolation:Test Rate. per minute per inch (test to be com feted bY.A.
o
licensed engineer .architect)
PROPOSED::SYSTEM INFORMATION:
Tank:size gallons (min. slze.1,000 gallons, add �50 gallons f..or:ea�h:garbage±cylinder r�:r
spa/hsjt tub
System.:.-::. .: Absorption field w/#Z stone T4tai length Each:Tr..ench: .... ft,
_ .
p g .
See a e<Pit w/#3 stone Hove many-,.. ;Size:
Alternative:System. Be;d or other type;
Holding Tank'System Total,regdired capacity? ze
,
#of tanks
Septic.tjpplication Revised DeceMber:2020
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bCONTACT.INFORMATION: PLEASE PRINT LEGBY OR TYPE,:PASENiAN EMAIL.
•. :Applicant.
Name(s) ', " `
i
Istl'ailih .Address, C:S/Z: vp w + ff
Cell:Phone::�( ). .. ... Land Line: _(� !
... .-
.Emai(: c)vn
• .:Primary Owner(s)::
Mailing Address,C/S/z IS
Cell.Phone:_(fig )� Z-3y3'tl land Line: _( )
Email.
L7:=Chee. k.if;a Fwdrk will be.performed by property:owner only
• Contractor:
Contact Names) ,�,5 �.� � �,
Contractor.tradec
Mailing:Address,;:C/S Z:: r. v iv.
Cell Phone:_( ) Land:Line: _( ) L
Email: . . . .
*.*.Workers' Com documehtation must:be submitted writh:this-_aPP1icat1oW'*
• E, ngineer s):
Name.(s):. . .
Mailing Address, C/S/Z:
.... - . ... ... ... .
CeII:P.hane ._( ) Land Line: `( )
Email:
Contact:Rerson for Compliance in:regards to,this project: iNnA.,
Cell_Phone:
Land Line: ( }.
Email:
NOTES: I;-Alarm system and associated electrical_work must be i inspected:by a Town ap'proved::electrical
inspection:agency 2. We will no longer allow systems to be co..vered until:such:time as.anas-built plan.is
received and.approved.The installed system.must match the septic ayout-on;:file--no exceptions. 3.:<As-
to pebuilt<drawingsmust"be5ubmittedprior e h g tothe:submitted
plans.:. lf�for any reason, the.building permit application is withdrawn; 30°.r pf`tt e fee.is retained by the
Town of Queensbury..After 1 year`from the initial application date, 100%.of the feels retained.
Declaration: Any permit.or appr..oval granted which is based.upon;or is grantedn:relianee..::upor:any:material
representation or failure to rr►ake a:material factor circumstance ktibwn.by.or on behalf of an applicant;shah be
void.I have.;read.the regulations 8nd;agreetq abide by,these and,.ail.requi Mtn ents.of the Town of Queens'bu'ry
Sanitary Sewage Oisposal-Ordinance,.
PRINT>:NAME:.::
.... ::. ...
pATE:`::�aih��:�i:. :::'a -
Septic Application Revised December:2026
TOWN OF QUEENSBURY
742 Bay Road, Queensbunj, NY. 12804-5902
Septic- System Checklist
tL�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 U 0 1 I`-'� p P Y 1 P P P � Ci IJU e.
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
Septic tank and pump stations 10'from foundation 50'from any well/lake/wetland.10'from any waterline
r�i 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
41seepage 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
t�Ldistance from bottom of trench or system 24"to bedrock or mottling 36"within 1000' of Lake George
Leech field 100' from watercourse or wetland
{./ Toe of mound or bottom of retaining wall 10' from property line 100'from well 20' from
Foundation
-tSQ Provide Engineer/Architect stamp for bed or design systems
Department of Health Approval for all mobile home park new systems Flood Plain requirements
I`, 2' above established flood elevation to bottom of system
All tanks anchored or 2' above flood elevation
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301.14-2-22 SEP-0117-2022
Dean, Jennifer I —�avIN->��-c�UEMI)Is u�� _
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