SEP-0047-2022 =:.r:
�'. SEPTIC DISPOSAL PERMIT Office Use Only
TIOIV Permit#: -d Zz�
Town of0yeensbury D E C tom' Permit Fee:$��
Invoice#:__ y
742 Bay Road,Queensbury,NY 1280 FEB 2022
P:518-761-8256 www..queensbury. t Septic Variance? Y 7 N 1
TOWN BUILDING& CODEsRY Flood zone? Y No\J �
Wetlands? Y Reviewed By:
Project Location:
Tax Map#:_ �3ct�
RESIDENCE INFORMATION:
JO 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 o
1992-Present 1110 Installed? (choose one) ❑
PARCEL INFORMATION:
Topography ❑ Flat Rolling ❑ Steep Slope jat _%' Slope
Soil Nature Sand ❑ Loam ❑ Clay ❑ Other, explain:
Groundwater At what depth? le,4b-
Bedrock/Impervious material At what depth? 7i
Domestic Water Supply ❑ Municipal ❑Well LCake
(if well or lake, water supply from any septic system absorption is
® ft.)
Percolation Test Rate: per minute per inch (test to be completed by a
licensed-engineer/architect)_:_ .
PROPOSED SYSTEM INFORMATION:
Tank size f 6Q 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: —J-L%3 �
Holding Tank System Total required capacity? ; tank ize
# of tanks
Septic Application Revised April 2021
i
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): Joh A igoomir�-
Mailing Address, C/S/Z: -),1 Via •)r vt[le l4y 12,3L5k
Cell Phone: Sig; 6 05- 86.s'L, Land Line: s'tzS 319 3 6— ,
Email:
• Primary Owner(s):
Name(s): t,fo>%a,, �3�L ;►-„��
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email: i
❑ Check if all work will be performed by property owner only
• Contractor:
Contact Name(s):�
Contractor Trade:
Mailing Address, C/S/Z: CD�Qb
Cell Phone: Z ((A Land Line:J,`'b
Email:
v
"Workers i Comp documentation must be submitted with this application**
• Eneineer(s):
Name(s): tf-1, 'vuk4 ,
Mailing Address, C/ /
Cell Phone: AJ
Land Line: _S 1Y,— qz �Z-Z0
Email: ��C. 4�lr 9W*1 l,a
t�in`1
Contact Person foci o pliance in regards to this project:
Cell Phone: Land Line: Z
Email: avirU,p4cc I@
e i .Cfly�
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 Gntil "suchlime 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 ofjQRensbury
Sanitary Sewage Disposal Ordinance.
q
PRINT NAME: JO tb 0 A6 130,0 i",91K
SIGNATURE: A �J �dy'`� DATE:
Septic Application Revised April 2021
TO WN OF Q UEENSB URY
742 Bay Road, Queensbury, NY. 12804-5902
Septic System Checklist
A.--plan to scale
I
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)
t-b All wells on property and adjacent properties shown LQ4�e' ✓ I e—x--
(� - 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
,,i,�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)
IK/, Septic tank sized for number of bedrooms and add 250 gals for Jacuzzi tubs/garbage grinder each
lLeech Field 20'from foundation 100'from any well 10'from water line
Seepage pit 150'from well 50'from septic tank
I✓ Seepage Pits 3-times diameter apart
Ir—I'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
H C l eech field 100'from watercourse or wetland
� . om of retainin 110'from property line 100'from well 20'from
Foundation
rovide Engineer/Architect stamp for bed or design systems
4—Department of Health Approval for all mobile home park new systems Flood Plain requirements
sS6 2' above established flood elevation to bottom of system
IiU All tanks anchored or 2' above flood elevation
NO-I / '
RPv;,zPri ail sno?i
WDK Wayne D.-Kant PE PLLC
2732 Touareuna Rd.
Amsterdam N.Y. 12010
Ph. 518.842.5220 License #070962
To Whom It May Concern:
Re: Addenda to Replacement On-site System plans. Lands of Boomer, 23
Woodspoint (Lockhart Loop), Queensbury, N.Y.
The following conditions must be met during:installation of replacement system:
1) The minimum depth of usable soil beneath absorption must be no less than
36". This is easily obtained as deep pit test revealed no mottling, GW or
bedrock to a depth of 6 .
2) A minimum of 10' separation must be maintained from.septic and dosing
tanks to water service line (dwelling uses lake water).
75.
Wa
2-18-22
Inspector's No.:
pEC- E0 VE
DEC 2 2 202 NWEALTH ELECTRICAL INSPECTION SERVICE, INC.
(Consulting'and Fire Inspection Services)_ Q 0�� 71AL2
trpor,,ted in the states of New York, Pennsylvania, and West Virginia) .
TOWN-OF QUEENSBURY
BUILDING&CODES
Desiring.Certificate of Approval, application is made for inspection of electrical installation in the premises described below. On
'demand,,applicant agrees.to,pay for inspection service in accord with schedule of charges.
Owner: �.r^;4� tip. o o
Type Building:Dwelling Other(please-specify):. r ��
Job Location: I `� :{,)r'"G'f! J, ��. 1 ..,;� City: (9 State: 1A\1
County: �_ ) ,1 l`�t' ?� Permit From:~ Permit# I
Swimming Pool: ' Inground: Aboveground: Bonding Date: l
Work New, Additional Bldg.- New Old 1 Ready for Inspection
Applicants Signature: i,V�.. � l,F ' �� '�� License#:
Please:Print Name: 'Phone.#: . 1
Applicants Address:' r� Ei f`-! '`D t -,01cA.; ("`i1_. i t Name of Utility:
City: �, Office To Be
.instate: Zip:f`� ,�: �f s��� Notified: Job#:
SPACE BELOW FOR USE OF INSPECTORS ONLY
Switches Water Heater Service Equipment Other list below
Receptacles Paddle Fan/Light Control Service Equipment -G.;1
GFCI Rece t Paddle Fan Panel t �F:«�4-__ /1 .�.o/)-'r< c
AMP Rece t Paddle Fan/Light Dryer Rec
Lights Vent Fan Washer Rec
Lights Air Conditioner Dishwasher Rec
Smoke Detectors AFCI Breaker Microwave Rec
Smoke/CO Detectors GFCI Breaker Garbage Disp Rec'
AFCUGFCI Breakers. Refrigerator Receptacle
Additional'apparatus for certificate:(Not listed above) Inspector Job Notes:
Installed By(if other than.applicant):
OFFICE USE ONLY ) e I l`1
Date Received:. Extra trip dates Ins ection Fee$
Service Date: /�(-) 1 CASH
R.W.Date:. 2 Check No.
Certificate No: � r ,
Final Date: _ I C, _ J_,)-3 Invoice
Certificate Needed? 4 CC
Date Sent: ter`" r Inspector sign in
Yes tr Dup next space Please print name Inspector: `
Original .Progress Final
THIS APPLICATION EXPIRES ONE YEAR FROM DATE MAKE ALL FEES PAYABLE TO C.E.I.S.INC.
•0.•
�v
1•�-G cense#p�pg62
W ayr'e ® p10,Ph•51 ���,��'� �� G�c�
oUareuna Rd. C��er � �,►, b "� o
2�32 pate 2 p
PS bui\t Ske�'ch �,�'��,� " �rn
,9 �/.._`_."`f_____-....� ate �`►N �° ��� �
OX
vj
w
1
WDK E� _Bui���
Wayne D. Kant P.E. PLLC
Consulting Engineer
2732 Touareuna Road, Amsterdam, N.Y. 12010
(518) 842-5220, N.Y.S. License # 070962
Replacement On-site Disposal System
Inspection Report r v
zc-
p �'l - Z. c�a N
Date of Ins ection:
R°m ^'
J �" i �� QZ IV
Address of System: � �(,.�Y�� �;P o rn�
cnc � , .
Client: �` �
Type of system: �� �, P �
Water Supply: ! IA IQ 01 CO
Percolation Rate Native:
Percolation Rate Native after site prep (if app 'cable): P1 /�
Percolation rate stabilized fill:
Comments/Changes.from original plans]:
i t ;o o l dvia l C.oryk
rod cd
This engineer has inspected the system during construction and to the best of my
knowledge the installation conforms ip the plans approved by local regulating authority,
except as noted above. Condition of system is reported as of time and date of inspection.
Conditions of system can and will change from that point forward. There is no actual or
implied warranty as to the long term function of the above system.
As-built Attache
Ways D.`KaiitPE: LLC
'