SEP-0674-2022 SEPTIC DISPOSAL PERMIT office use only
APPLICATION PermitM. �.(o .2RZ2—
ro orQiieensbury 9 V y Permit Fee:$ Q_D—
Invoice M
742 Bay Road,Queensbury,NY 12804 NOV 0 7 2022
P:518-761-8256 www.a6eensbury.ne4 Septic Varian e? NO
TOWN OF QUEENSBURY Flood zon
BUILDING&CODES
Wetlands? Reviewed By:
Project,Location: 23 Seward sfiree--r- .
Tax Map#: �2 . 1 $ — 2.-��
RESIDENCE INFORMATION: .
Year Built ' Gallons #of bedrooms: X gallons per =total daily#low
per day bedroom Garbage Grinder Yes No
1980orolder 150 Installed?. (choose:one) .
❑
1981-1991 130 Spa or Hot Tub : Yes No
1992-Present 110 Installed? (choose one). ❑
o 330
Nevi �. �cTV 12-�5 l F NELE SS 112`-I (=01Z _S4 S M I.I FES'P�}N
PARCEL INFORMATION:
Topography ❑ lat oiling ❑ Steep,Slope. - % Slope .
Soil Nature Sand ❑Loam ❑ Clay. ❑ Other, explain:
Groundwater. At-what depth:? .+.
Bedrock/Impervious material At:what_depth?. . .NOT E►�iCO V NEE
Domestic Water Supply Municipal ❑Well ❑Lake.
(if well or lake, water supply from any septic system absorption is
ft.)
Percolation-Test Rate: (�J per minute per inch (test to be completed by a.
licensed engineer/architect)
PROPOSED SYSTEM INFORMATION:
Tank size I gallons (min. size 1000 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;. 25 x .lam `. G-801 W DIBo.X
Holding Tank System Total required capacity?_ tank size
# of tanks
Septic Application Revised July 2022
t
y,
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL.
• Applicant:
Name(s): �/3'Rld n/ ��i�,••FN�-s
Mailing Address, C/S/Z: 2�f �,coN�� !�Z• �,,F�Nsb,,,r�.�, IVY
Cell Phone: T"k 5'S2-y2S3 Land Line: 4'/p 7.5z-�3G9
E m a i l: bxinN.C ,et. co r•.
• Primary Owner(s):
Name(s): f�ie, aJ SiecNr.Clh,..rvls
Mailing Address, C/S/Z: 2Ys' CrtoN ink /2.1..,QF�y, My 2g�y`
Cell Phone: ,!;�/$' y 32-y2 S3 Land Line: S 1- 7 72-ay6g .
Email: h�,�,v. c1,Fr�F�• s. 4�1�v @�we►:l .cc•++
❑ Check if all.work will be performed by property owner only
• Contractor:
Contact Name(s): 1�!-gvggg /7RgI/at
Contractor Trade:
Mailing Address, C/S/Z: /mac .L�zr�.�-+E R� ,/t'79�7 �Jb7, ^17
Cell Phone: s'/s 7yG -37Go Land Line: ilt 7V-?;L5'1
Email:
**Workers' Comp documentation must be submitted with this application**
• Eneineer(s)•
Name(s): PUC/I NSLI l. 1612Gi h TFMOE
Mailing Address, C/S/Z: 1?24- VOC PJVF—
Cell Phone: . Land Line: 51%--741
Email: FiPNALL- @ Ny CAV2. aW."M
Contact Person for Compliance in regards to this project: r!:;tUw.l 4-tAw
Cell Phone: Land Line: '518-'A1-0Uf>
Email: 60V1416) IY1Kmlp—r-r.com.
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 Queens-bury Sanitary Sewage Disposal Ordinance.
PRINT NAME: C,(l,N--Cc N �S
SIGNATURE: ( DATE: 2-
Septic Application Revised July 2022
TOWN OF QUEENSBURY
742 Bmj Road, Queensbury, NY. 12804-5902
Septic System Checklist
Plan to scale
411eceived Deep hole pert test results from engineer/Architect if applicable(Town Approved Engineers and
Architects;June 30 to April I5 Town Engineer for unapproved Engineers and Architects)
AVAII wells on property and adjacent properties shown - �'`-�'�
ANater line shown Municipal or well 10'separation to any part of system
t6setback 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
I v Neptic 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 20'from foundation 100'from any well 10'from water line
4k—Seepage pit 150'from well 50'from septic tank
� Seepage Pits 3-times diameter apart
LA Septic tank and pump stations over 30_g@ Lons 50'from watercourse or wetland
14distance from bottom of trench or syst m 24" bedrock or mottling 36"within 1000'of Lake George
Leech field 100'from watercourse or wetland
gToe of mound or bottom of retaining wall 10'from property line 100'from well 20'from
Foundation
J§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
V n.rioari All C/)n 11