SEP-0426-2022 ,w
SEPTIC DISPOSAL PERMIT office Use only
APPLICATION Permit#: SAY— v �ZCe 2o2Z
Town ofQuecnsbury ermit Fee:$ (�
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I nvoice#: S / L 4
742 Bay Road,Queensbury,NY 12804 � [P:518-761-8256 www.aueensbury.net eptic Variance? YENBBURY lood zone?CODEB etlands? Y eviewed By:
Project Location: r"
Tax Map#: 30( . t-z,_ Z"
RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms: X gallons per =total daily flow
p bedroom Garbage Grinder Yes No
1980 or older 1 �/p ?� Installed? (choose one) ❑
1981-1991 130 Spa or Hot Tub Yes No
1992-Pres t 110 Installed? (choose one) ❑
-1 Uvt,�,v SAJ,nS V ) (-es I tit•. 'I�pJ wf
PARCEL INFORMATION:
Topography RFlat Rolling ❑Steep Slope % Slope
Soil Nature Sand ❑ Loam ❑ Clay ❑ Other, explain:
Groundwater At what depth? _�
Bedrock/Impervious material At what depth?AU A
Domestic Water Supply .Municipal ❑ Well ❑Lake
(if well or lake, water supply from any septic system absorption is
ft.)
Percolation Test Rate: ,ni per minute per inch (test to be completed by a
licensed engineer/architect)
PROPOSED SYSTEM INFORMATION:
Tank size b00 gallons (min. size 1,000 gallons, add 250 gallons for each garbage cylinder or
spa/hot tub11A& I ��
System Absorption field Total length Z ft.; Each Trench 2 3 ft.
Seepag it w/#3 stone How many: ; Size:
Alternative- a Be or other type• '
Holding Ta ste Total uir capacity? ; tank size
#oft s
Septic Application Revised April 2021
=M
} CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): nna; Gi►Am.,
Mailing Address, C/S/Z: ho TO 4+VM;1k F, � �s �J � ��^� A^� /V y f 2" 2 7
Cell Phone: 5_/,q - 3% 1— 31 2 ') Land Line:
Email: /'\c ke^,)e o Co^i4c-1."Q yc L,oa
• Primary Owners :
Name(s): i()c
Mailing Address, C/S/Z: tize V" prtyf
Cell Phone: Land Line:
Email:
❑ Check if all work will be performed by property owner only
• .Contractor•
Contact Name(s): 5k6i i tl A k?^nC
Contractor Trade: 'OXc(�V-,-41
Mailing Address, C/S/Z: I O ro 4V,",0, Fig Of 12)
Cell Phone: S/ ,3S Land Line:
Email:
**Workers' Comp documentation must be submitted with this application**
• Eneineer(s):
Name(s):
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email:
Contact Person for Compliance in regards to this project:,C2,-,.k (u�-ov'
Cell Phone: 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: LV N I/' i C �4 -PM/
SIGNATURE: DATE:
Septic Application Revised April 2021
TOWN OF QUEENSBURY
742 Bay Road, Queensbuq, NY. 12804-5902
Septic System Checklist
N 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
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
Septic tank to foundation crawl space/slab on grade,grade in crawl space must be above top of septic tank
for0',Separation required (field verification required)
Septic tank sized for number of bedrooms and add 250 gals for Jacuzzi tubs/garbage grinder each
1 Leech Field 20'from foundation 100'from any well 10'from water line
t*% 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
VNN 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
Department of Health Approval for all mobile home park new systems Flood Plain requirements
2' above established flood elevation to bottom of system
All tanks anchored or 2' above flood elevation
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From:the septicfank; partially treated:ei :luentflows For proper..effluent:purification,:the d. istance between t iearench k attom `
icall has twc ;or More and the water table should be:a ual to or seater than Iqe:rninirr L m
tree files. Th sl s, where_eYP Y Q g
ffluent is nature fl y purified distance allowed by your local health department: The .soil acts a,s a
as it percolates down through soil biological filter, removing harmful substances before tr effluent rJaches.
the groundwater
'.�: ® Infiltrator Water Technologies:manufactures;ciiamber s t.3tems and EZflow
Geosyr,thetic Aggregate systerns,which are both used ;� leachfield
installations:
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Infiltrator -
chambers-
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eptid Tan
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„ :Effluent.flows.rnto the Infiltrator Quick4 eachfield.where it`.
I s naturally purified as it percol,.�tes down through the soil...: EZflow geosynthetic leachfield:. '
5 ..::
301.12-2-48 SEP-0426-2022
Nick Norton
33 Zenas Dr.
Residential Septic Alt. 7