SEP-0275-2022 SEPTIC DISPOSAL PERMIT Office Use Only
APPLICATION Permit#:
Town of Qucensbury j
D L°� C 0 J Pam' Permit Fee:$ V
�� Invoice#: I ��
742 Bay Road,Queensbury,NY 12804 NIAY 11 2g,22
P:518-761-8256 www.gueensburV.net Septic Variance? Y N
TOWN OF QUEEN MY Flood Zone? Y
BUIL INN& C ES
Wetlands? Y Reviewed By:
5
Project Location: 41 0 1
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) ❑ 21
PARCEL INFORMATION:
Topography [Flat Rolling ❑ Steep Slope % Slope
$oil Nature [Sand ❑ Loam ❑ Clay ❑ Other, explain:
Groundwater At what depth?
Bedrock/Impervious material At what depth?
Domestic Water Supply X 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 4000gallons (min. size 1,000 gallons, add 250 gallons for each garbage cylinder or
spa/hot tub
System Absorption field w/#2 stone Total length IL' P ft.; Each Trench J 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
e y�
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• A licant-
Name(s): Ky e, . o,,,�c
Mailing Address, C/S/Z: o
Cell Pho e: Land Line:
.Covs�
• Primar Owner
Name(s):
Mailing Address, C/S/Z: ,� ��►�s�,vw-�, ) ���
Cell Phone: Land Line:
Email:
❑ Check if all work will be performed by property owner only
• Contractor:
Contact Name(s):
Contractor Trade: of
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email:
"Workers' Comp documentation must be submitted with this application"
• En ineer s :
Name(s):
Mailing Address, C/S/Z:
Cell Phone: 4q, A17— OoU Land Line:
Email:
Contact Person for Compliance in regards to this project:
Cell Phon : Z,j7-X7D`7 Land Line:
Email: 0V , .l rr k .G o►-�—�
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 Dis osal Ordi
PRINT NAME: �� C�
SIGNATURE: --� DATE �/�' ��
Septic Application Revised April 2021
I OWW OF QUEENSJBURY
742 Bay Road, Queensbuny, NY. 12804-5902
Septic System Checklist
�4urplan to scale
463Received 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)
A)#"- All wells on property and adjacent properties shown.
Water line shown Municipal or well 10'separation to any part of system
61�90Setback 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
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)efrom foundation 100'from any well 10'from waterline
4Jeepage pit 150'from well 50'from septic tank
�v eepage Pits 3-times diameter apart
�IdSeptic tank and pump stations over 30 gallons 50'from watercourse or wetland
listance from bottom of trench or system 24"to bedrock or mottling 36"within 1000' of Lake George
Qld 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
qeJProvide Engineer/Architect stamp for bed or design systems
�tlDepartrnent of Health Approval for all mobile home park new systems Flood Plain requirements
fJy 2' above established flood elevation to bottom of system
All tanks anchored or 2' above flood elevation
';7
RPviged 4/15/2021
ENGINEERING, PLLC
Civil Engineering Structural Design Structural Inspection
RECORD PLAN DRAWING SUBMISSION
FOR
SEPTIC SYSTEM REPLACEMENT
Date: June 25,2022
JUN 272022
To: Town of Queensbury
John O'Brien TOWN OF OUE=FNSBURY l
Building Department BUILDING&CODES- _I
742 Bay Road
Queensbury,NY 12804
Re: Forest Park-Mobile Home Park
Queensbury,NY 12804
To Whom It May Concern:
Find enclosed a septic system record drawing (l 1x17) depicting the replacement septic
system as it was constructed at the below noted address.
Replaced Septic Systems at:
Forest Park MHP
Gregwood Circle lot: #39
Briwood Circle lots: #96 and 494-95
Please let me know if you have any questions.
If you have any questions please call.
Sincerely,
Ryan K. Riper,P.E.
Encl.
225 Ruggles Road
Saratoga Springs,New York 12866
Cell:518.817.0099
e-mail:RyanRiper@RKengineering.us