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SEP-0141-2022 SEPTIC DISPOSAL PERMIT Office Use Only APPLICATION Permit#:_-EC4 f Town of Qgccnsbun Fj Permit Fee:$ Invoice#: 742 Bay Road,Queensbury,NY 12804 � P:518-761-8256 www.gueensburV.net Septic Variance? Y LN Flood Zone? Y G Wetlands? Y & Reviewed By: Project Location: .L"'i-v �s, /'��/� DEC0 V IE Tax Map #: 17d�t i / - s Z. k1AR 2 8 2022 RESIDENCE INFORMATION: TOWN OF QUEENSBURY Year Built Gallons #of bedrooms: X gallons per =total daily flow RI In I(,R. r)r=.q per day bedroom -Marbag�'eZfflyder--- es 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 lat Rolling ❑ Steep Slope %Slope Soil Nature LF ''sand ❑ Loam ElClay ElOther, explain: Groundwater At what depth? Bedrock/Impervious material At what depth? Domestic Water Supply ([Municipal ❑ 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 ems 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 10C ft.; Each Trench 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 1� CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL • Applicant: Name(s): y-e_J-y'W,14/ Mailing Address, C/S/Z: --Cell Phone: Land Line: 47X- & /Oy-,' Email: &1C)0g ra'pS �cE�c1-7 • Prim n s : Name(s): �� Ti�� Mailing Address, C/S/Z: 7 c c� ,1 re-,,J �v�y I-zgo y� Cell Phone: Land Line: 09 Email: ❑ Check if all work will be performed by property owner only • Contractor: Contact Name(s): cc-.� Contractor Trade: Mailing Address, C/S/Z: ' 10 O — Cell Phon : ©— �- r2 07 Land Line: /d Email: Cl �._ICXVe ri4CIV �7�jj ,�01�� "Workers' Comp documentation must be submitted with this application" • En ineer s : Name(s): 40i111)e11A /J Mailing Address, C/S/Z: Z r Gt,'A ./ zgolz Cell Phone: ��l��T� Land Line: Email: Contact Person. Compliance in regards to this project: f Cell Phon : �� �� ® Land Line: Email: 6-hVt1.e f L1 216�-G 073-/ 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 t` ulations and agree to abide by these and all requirements of the Town of Queensbury Sanitary Sewage DJspo l Ordinan i PRINT NAME: y SIGNATURE: DATE: 0 Z-, Septic Applicati n Revised April 2021 J TOWN OF QUEENSBURY 742 Bay Road, Queensbury, NY. 12804-5902 Septic System Checklist - 5Plan 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 M w) I G �Z' eater line shown Municipal or well 10'separation to any part of system KI ( Setback to property lines show 10' or more for any part of system 9'�-ISeptic tank and pump stations 10'from foundation 50'from any well/lake/wetland 10' from any waterline 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) J"SSeptic tank sized for number.of bedrooms and add 250 gals for Jacuzzi tubs/garbage grinder each Leech Field Ofrom foundation 100'from any well 10'from water line / Seepage 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 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 V-P—AProvide Engineer/Architect ��epartment of Health Approval for all mobile home park new systems Flood Plain requirements )J62' above established flood elevation to bottom of system A�d All tanks anchored or 2' above flood elevation uP���P�ail Semi N K STAATETE O OF Department F OPPORTUNITY- of Health KATHY HOCHUL MARY T.BASSETT,M.D.,M.P.H. KRISTIN M.PROUD Governor Commissioner Acting Executive Deputy Commissioner March 18, 2022 -rY �(V E t Ryan K. Riper, P.E. 022 RK Engineering, PLLC ()�.' ,�i`4B�RY 225 Ruggles Rd EIiJBE_i)f3�ti ss CODES Saratoga Springs, NY 12866 RE: Forest Park Mobile Home Court, Facility 56-6822 Replacement Onsite Wastewater Treatment Systems at Briwood Lot 18 and Woodland Path Lot 19 Queensbury (T), Warren County Mr. Riper: We have this day, approved the plans and specifications for the above-referenced project. Application for this project was duly made by you on plans titled, "Replacement Septic System," and was most recently received by this office February 11, 2022. The project includes installation of replacement onsite wastewater treatment systems.to serve Lot 18 on Briwood Circle and Lot 19 on Woodland Path. The system serving Lot 18 consists of one 1,000-gallon septic tank and ADS Hancor ARC 24 chambers, to serve one 3-bedroom home. The system serving Lot 19 will consist of the same components. Approval of these plans is conditioned on the following: 1. That the proposed works be constructed in complete conformity with the approved plans or amendments thereto; 2. That all components of the proposed works be installed, operated, and maintained as per the manufacturer's specifications; 3. That approval be granted by other agencies or municipalities have jurisdiction; 4. That the design professional inspects the construction and provides certification to this office that construction was completed in accordance with the approved plans. Certification shall also be provided to the Town Office Building and Code Enforcement. The responsibility for the design of the sanitary system lies solely with the design professional and the proper operation of the sanitary system lies solely with the owner. The purpose of the Department of Health review is for compliance with the New York State Sanitary Code and in no way guarantees proper system operation. A set of approved plans is being retained in our files. Glens Falls District Office,77 Mohican Street,Glens Falls,NY 12801.518-793-38931 gfdo@health.ny.gov Sincerely, Brendan O'Connell Engineer Trainee NYSDOH —Glens Falls District Office 77 Mohican St. Glens Falls, NY 12801 (518) 793-3893 cc: Rebecca Bussert, District Director, Glens Falls District Director Kevin Kenyon, P.E., Glens Falls District Office Joel Brown, RHP Properties John O'Brien, Town of Queensbury