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SEP-0587-2022 0 Office Use Only 16 D IE C 95 0 JE Permit#: Town ofQucensbW SEP 20 Permit Fee:$ 742 Bay Road,Queensbury,NY 12804 2022 Gy P:518-761-8256 www. ueensbu .net Invoice#: 5 -/ TOWN OF QUEENSBURY BUILDING& D0- P Flood Zone? Y eviewed By SEPTIC DISPOSAL PERMIT APIICA Project Location: V-p,,j L Tax Map #: RESIDENCE INFORMATION: Year Built Gallons #of bedrooms: X gallons per =total daily flow per day bedroom Garbage Grinder Yes 1 1980 or older 150 Installed? (circle one) 1981-1991 130 Spa or Hot Tub Yes Now 1992-Present 110 �3v_ 3 3 CD Installed? (circle one) ✓r PARCEL INFORMATION: Topography Flat Rolling Steep Slope % Slope Soil Nature Sand Loam Clay Other, 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: a 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 ft.; Each Trench 9'L-:1 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 December 2020 �. CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL • Applicant: Name(s): �'�� Mailing Address, C/S/Z: 2,Tq Cell Phone: _( 56 ) gS?- 9ogg Land Line: _( ZZ a1 p Email:- LVu (Z ar^vV.c Se,r h'( • Primary Owner(s): Name(s): nAe_P Mailing Address, C/S/Z: P0, Q L/. R. ye epjiS b..-­�:z, 4-';K Cell Phone: ,,,-( SIF Land Line: _( ) Email: 0 Check if all work will be performed by property owner only • Contractor: Contact Name(s): Contractor Trade: Mailing Address, C/S/Z: Cell Phone: _( ) Land Line: _(. ) Email: **Workers' Comp documentation must be submitted with this application** • Engineer(s): Name(s): Mailing Address, C/S/Z: Cell Phone:_( ) Land Line: _( ) Email: Contact Person for Compliance in regards to this project: �C,Y.J Cell Phone: (:g-(q ) ?S 7 cI oq`3 Land Line: �) Email: ) ULV PVA,%(4:A01'n( 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: �v✓ vd ( SIGNATURE: DATE: Septic Application Revised December2020 TOWN OF QUEENSBURY 742 Bay Road, Queensbu-ry, NY. 12804-5902 Septic System Checklist Plan to scale Received Deep hole pert test results from engineer/Architect if applicable(Town Approved Engineers and Architects;June 30 to April 15 Town Engineer for unapproved Engineers and Architects) WU All wells on property and adjacent properties shown Water line shown Municipal or well 10'separation to any part of system 16Setback to property lines show 10'or more for any part of system iaseptic tank and pump stations 10'from foundation 50'from any well/lake/wetland 10'from any waterline YiLSeptic 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) t—Septic tank sized for number of bedrooms and add 250 gals for Jacuzzi tubs/garbage grinder each Leech Field 20'from foundation 100'from any well 10'from water line 6—Seepage pit 150'from well 50'from septic tank LP(Seepage Pits 3-times diameter apart IASeptic 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 tLeech field 100'from watercourse or wetland Toe of mound or bottom of retaining wall 10'from property line 100'from well 20'from � Foundation A /"" Provide Engineer/Architect stamp for bed or design systems ALADepartment of Health Approval for all mobile home park new systems Flood Plain requirements 2'above established flood elevation to bottom of system I"U All tanks anchored or 2' above flood elevation s ' Gor, le daps 4302029.5"N 73042'59.9"W CD (7t _ )•, •yr�' t bey V.s'F:'ay�yg4y.R '':a -'y' :Aa,:gpap��^ u M.'r, jR ,,, 'yt," •'N j' � 3 iM.,i�'.'%rI' �-. K� ova, E -'.�'� RE� .r. q��=a Y '�'•��, .w.,"c- gd;.�vgrl�4: -,P � a"^ � 4 ' 4. [� ,L ."E.: ifs..-' ,�.,'+i ,+•`s.�' � .x.. .. �, ,'„�: ,ti." - _ v*. ,w°. .'&,&, A - •____r.._a...._.....v. e. Map data©2022,Map data©2022 20 ft A r, Z,O ov SEP z p - - 2022 �11 295.14-2-25 SEP-0587- s OWN OF QUEENSBURY TOWN or- >' ]ones Chris 2022 TOWN OF QU _NSBU C�lli� llf�; U�� BUILDING ,DESRE Bult cli`JG of 1�D�:�o � oQ� 83 Mountain View Ln � Based on our limi}ed examination,compliance"T"�—���-�-..___I Revi,.x11Ue By: with our comments shall not be construed as Residential Septic Alteration indicating the plans and specifications are in Date: --- - full compliance with the Building Codes of New York State, l ------ - - -------- ---------- AS BUILT -- -------- ------------------ ----------------- ---- - - - - - ----- --- - -- - - ----- -- - - - - - - --QD - -- � --- 5 -- - ---- - = J