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SEP-0185-2022 SEPTIC DISPOSAL PERMIT Office Use Only APPLICATION Permit#: O f 9S Town afQocens6ury Permit Fee:$ 00 Invoice#: ,, YEa;L 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.gueensbury.net Septic Variance? Y N Flood Zone? Y N ` Wetlands? Y N Reviewed By: Project Location: 13Siindl���a c �s1 kVr& Tax Map #: �� RESIDENCE INFORMATION: Year Built Gallons #of bedrooms: X gallons per =total daily flow per day bedroom Garbage Grinder Yes No 1980 or older 150 Installed? (choose one) ❑ 1981-1991 130 Spa or Hot Tub Yes No 1992-Present 110 Installed? (choose one) ❑ PARCEL INFORMATION: Topography Flat Rolling ❑ Steep Slope % Slope Soil Nature and ❑ Loam ❑ Clay ❑ Other, explain: Groundwater At what depth? Bedrock/Impervious material At what depth? Domestic Water Supply icipal ❑ Well ❑Lake (if well or lake, water supply from any septic system`absorption is ft.) Percolation Test Rate: /- per minute per inch (test to be completed by a licensed engineer/architect) PROPOSED SYSTEM INFORMATION: Tank size /Q12 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 ZSV ft.; Each Trenches 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 April 2021 CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL • Applicant: Name(s): _4tri'`nsi; S'bV- CAZI:,'VIpp% � ZOP Mailing Address, C/S/Z: sza,D ► J_ Q1 Cell Phone: Land Line: Email: • Primary Owner(s): Name(s): 9 ` Mailing Address, C/S/Z: ,�� ,atN �. m1}�i1 2cQ ��� Cell Phone:(51-6)311Q -01gc0 Land Line: Email: CLLSV1'jnQrnd dgmai1.rOrn ❑ Check if all work will be performed by property owner only • Contractor: Contact Name(s): Oif-n, �Aur&mv"Wt 4 ��uc Contractor Trade: cLy L Mailing Address, C/S/Z:5Ct O m l_c Id,WG7 0 (S)119) WS7-90q 3 Cell Phone: L oL,_ DP.EAd_er Land Line: 15$)7q3 zZqn E m a i 1: Cn of-41 4ce 1i C_®Vi04r q,r I . **Workers omp documentation must be submitted with this application** • Engineer(s): Name(s): Mailing Address, C/S/Z: Cell Phone: and Line: Email: Contact Perso r Compliance in regards to this project: Cell Pho . `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 Disposal Ordinance. _...__.PRINT NAME:._ _/ _ _. SIGNATURE: DATE: Septic Application Revised April 2021 TOWN OF QUEENSEURY 742 Bay Road, Queensbuny, NY. 12804-5902 Septic System Checklist No Plan to scale "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) !" 6All wells on property and adjacent properties shown Water line shown M _al or well 10'separation to any part of system e Setback to property lines show 10'or more for any part of system qt�-&ptic tank and pump stations 10'from foundation 50'from any well/lake/wetland 10' from any waterline �/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) �:C&ptic tank sized for number of bedrooms and add 250 gals for Jacuzzi tubs/ arbLge grinder each S Leech Field 20'from foundation 100'from any well 10'from water line (N t I V'% 4seepage pit 150'from well 50'from septic tank 4/Seepage Pits 3-times diameter apart SSeptic tank and pump stations over 30 gallons 50' from watercourse or wetland S distance from bottom of trench or system 24" to bedrock or mottling 36"within 1000' of Lake George tl� CLr4`� Nun- �1"/ I;-e b-e.. S a� (7251 eech field 100'from watercourse or wetland 11L� Toe of mound or bottom of retaining wall 10' from property line 100'from well 20'from Foundation N 6 Provide Engineer/Architect stamp for bed or design systems I-� Department of Health Approval for all mobile home park new systems Flood Plain requirements W6 2' above established flood elevation to bottom of system CJ6 All tanks anchored or 2' above flood elevation R P..ViRRH d/1'V?M1 FILE COPY 1. TOWN OF QUEENSBURY BUILDING DEPARTMENT _ __ __ Based on our limited ek"amination,coant: T�1I�N OF QU�ENSBURY with our comments shall not be constn. indicating the plans and specifications �U�L171�9G CODES DEPT. full compliance with the Building Cod, E New York State. 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