SEP-0703-2021 d
SEPTIC DISPOSAL PERMIT Office Use Only �~0-34 o- 2az1
` y APPLICATION Permit#: Ste— 0'4'0 — 2O 21
6
Town of Queensbury 5-
Permit Fee:$
Invoice#: 40.-1"
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.aueensbury.net Septic Variance? Y
Flood Zone? Y N
Wetlands? Y N Reviewed By:
Project Location: 49 BIRCH ROAD °� _ P
Tax Map #: 289.13-1-25 i
RESIDENCE INFORMATION: TOWN OFt
Year Built Gallons #of bedrooms: X gallons per =total daily flow° Uii_1f6<<,
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 3 110 330 Installed? (choose one)
PARCEL INFORMATION:
Topography Flat Rolling Steep Slope % Slope
Soil Nature I Sand WI Loam ❑ Clay Other, explain:
Groundwater At what depth? >54"
Bedrock/Impervious material - At what depth? >54"
Domestic Water Supply Municipal ❑ Well VLake
(if well or lake, water supply from any septic system absorption is
ft.)
Percolation Test Rate: 2:30 per minute per inch (test to be completed by a
licensed engineer/architect)
PROPOSED SYSTEM INFORMATION:
Tank size 2.000 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 ft.
Seepage Pit w/#3 stone How many: ; Size:
Alternative System Bed or other type: 15' (Avq. Width)X 30' PIPE-IN-STONE BED
Holding Tank System Total required capacity? ; tank size
# of tanks
Septic Application Revised April 2021
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): PAUL &SUZANNE MCPHILLIPS
Mailing Address, C/S/Z: 49 BIRCH ROAD. LAKE GEORGE, NY 12845
Cell Phone: Land Line:
Email:
• Primary Owner(s):
Name(s): SAME AS APPLICANT
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email:
❑ Check if all work will be performed by property owner only,
• Contractor:
Contact Name(s): IBS Septic Service
Contractor Trade:
Mailing Address, C/S/Z: 2 Lower Warren Street, Queensbury
Cell Phone: 518.361.2465 Land Line: 518.798.8914
Email: cbell@ibsseptic.com
**Workers' Comp documentation must be submitted with this application**
• Engineer(s):
Name(s): HUTCHINS ENGINEERING PLLC
Mailing Address, C/S/Z: 169 HAVILAND ROAD
Cell Phone: Land Line: (518) 745-0307
Email: THUTCHINS@HUTCHINSENGINEERING.COM
Contact Person for Compliance in regards to this project: TOM HUTCHINS, P.E.
Cell Phone: Land Line: (518) 745-0307
Email: THUTCHINSHUTCHINSENGINEERING.COM
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: {1r{� � jcc 6,6-c- ekikss
SIGNATURE: DATE: 0/2_ O
Septic Application Revised April 2021