SEP-0593-2022 SEPTIC DISPOSAL PERMIT office use only
.4k-� APPLICATION Permit#: cl'p-'OG�'1�y'2�?,2
Town ofQucenmus Permit Fee:$G,
Invoice#; v'
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.gueensbury.net Septic Variance? Y C�)
Flood Zone? Y
Wetlands? Y Reviewed By:
Project Location: ,SQL A11119 vw
Tax Map#• c1 ^ i
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 U Installed? (choose one)
l ❑ `�
PARCEL INFORMATION:
Topography Flat Rolling ❑ Steep Slope % Slope
Soil Nature QSand ❑ Loam ❑ Clay ❑ Other, explain:
Groundwater At what depth?
Bedrock/Impervious material At what depth?ILL
Domestic Water Supply RMunicipal ❑Well ❑Lake
(if well or lake, water supply from any septic system absorption is
ft.)
Percolation Test Rate:/-5- per minute per inch (test to be completed by a
licensed engineer/architect)
PROPOSED SYSTEM INFORMATION: Ape,j 10-U-0 / � to
Tank size f W gallons (min. size 1,000 gallons, add 0 gallons for each garbage cylinder or
spa/hot tub
System Absorption field w/#2 stone Total length-7�ft.; Each Trench 3-0 ft. 11v
Seepage Pit w/#3 stone How many: ; Size: v20
Alternative System Bed or other type:
Holding Tank System Total required capacity? ; tank size ;
#of tanks -
Septic Application Revised April2021
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant.,
Name(s): , V
Mailing Address, C/S/Z: o � Z 2
Cell Phone: r1j -75?6- T760 Land Line: ?Zs"-7• Primary Owners : 8r0_'1VX_(A_K
Name(s): 0 r3
Mailing Address, C/S/Z: S_ ' /, ViL
Cell Phone: If Land Line: .
Email:
❑ Check if all work will be performed by property owner only
• ' Contractor:
Contact Name(s): ` n'Nv 2�ue/t_
Contractor Trade:
Mailing Address, C/S/Z: PO e gig ZZ 7 6�4-,Ls e;W4 !Z Fri
Cell Phone: 6�1&- -ZNgr' -_3 7" Land Line:
Email:
**Workers' Comp documentation must be submitted with this application**
• Enizineer(s)•
Name(s):
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email:
Contact Person for Compliancp in regards to this project: 4Ae
Cell Phone: S 7 � -^�7K`o 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 'sposal Ordi ance.
PRINT NAME: _C
SIGNATURE: DATE: Z�'-Z�
Septic Application Revised April 2021
TOWN OF Q UEENSB URY
742 Bay Road, Queensbury, NY. 12804-5902
Septic System Checklist
Plan to scale
WReceived 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 �L'�4c1D�t
*ater line shown Municipal or well 10'separation to any part of system
eetback to property lines show 10'or more for any part of system
Aseptic tank and pump stations 10'from foundation 50'from any well/lake/wetland 10'from any waterline
Qk—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
l-Leech Field 20'from foundation 100'from any well 10'from water line
Seepage pit 150'from well 50'from septic tank
LIASeepage Pits 3-times diameter apart
ice-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
9A—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
�Cxll tanks anchored or 2' above flood elevation
V—A..A All VIM I
TOWN OF QUEENSBURY
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Reviewed By: — Aan3®Oa�ONralln8
Date: 8SN33no O NMO.L
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TOWN OF QUEENSBURY 4 ti
BUILDING DEPARTMENT
Based on our limited examination,compliance
With our comments shall not be construed as ' -
indicating the plans and specifications are in �.
full compliance with the Building Codes of
New York State.
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