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SEP-0867-2021 .. . office.use::Only. Permit#: (o -2©ZA - 7P9;'SZ 1S8a=y9 1=82 Permit Fee::Road . . � ..;Qu0sbury;NY 1280g 56ewww.auee6*46 A/A 4 Flood Zone? Y Rev►e.We By...rV� SAL.PERMIT�iPRLICATI,ON Vl�v�a�nca,. �..�°. Project Location: Lavr� EC 0 8 2021 Tax.:Map.#: OF QUEENSBURY BUILDING&CODES ....... ... .. RESID:ENCEINFORtVIAT10N. . .:.. Year;Built Gallons #ofbedrooms: X gallons per =total daily flew per:day. ..bedroom a Garbage..GrHn der Yes o 1990..or.older : ::150. . fed?::(circle lnsta(::........ . .. ....;;one).. 19814m: 130. _... _.._ Sj�a r?r.Hot Tuk ' Yes No w. 1992:Present: 110 (circle„arie} Installe PARCEL:INFORMATION TopographyFtat Rotatng: - .Stepp Slope. Slope. Soil Nature' Sand:;;';: _.Loam Ciay Other,-ex la: Groundwater. At wha:t:depth?� Bedrock/i:mperuio.us:ma#erial., :At=rrirfat.depth ' D.omstic 1Nater':Supply _ Municipal _VII'ell .�Lake. (if well or take, Water:suppl.i frprri any septic.system.absorption is; ... .. _.. ... ft.} =� Percolation Jest: Rate: t-%0 . per minute:per Inch {test;to be car>r pteted by a. ......... .Irc�nsed:engwneer/architect): : PROPOSED`SYSTEM:INFORMATIOM .... ....... ......... Tank::size: 1 gallons (min. size.1;0.0.gatl.ons- add 25E)gall+ its for eacf7:ga.rbage cylinder or :spa hot;;tub ... .. . ,. :4. System; Abstirptian'field w/#Z sto.ne Total length ft : Ea�iiTren.ch::: ..� ft, .... See a e:Pit:w>#3 stone Houi many::. ;Size: p g ... . 1 m ... A term-b e:System Bed o:r other type. Htildin Tank System Total required ca,:,:..ty:$ tart: 'S1Z�_ #of tanks, Sepci,G,a„pplication Rvised becember: ud i ONTACT'INFORMATION .PLEASE.PRINT LEGIBLY OR TYPE PLEASE:INCLUDE AN:EMACL �� A' licant� Name{sj: C t n g Mailin .:Address; CLn CellPhone: ( e _ L _ - a'nd Lin 1 Email`: )2�r s LCW of Se C4;C r Cam' • Prlm .O.wner s ......... ........ ... ..... MailingAdtl'ress, CJSjZ v� CeII:Ph.one::_( j La:nd:Line:: �{ j Email•: Cl tfieck if all uvork will be performed b roe owner.©nl y p p rty :. : . r.�.Y. 'Contractor::; °.costa-(Name{sj S �. ch Contractoe:Trade: L lsL U S Maili:ng:Address;.Cf 5/Z:. . Dell Phone._� 1)? j (60-92 Land Line:: Ernail: . C Workers.!Xomp documentation must.be:submitted 3iyiti't:thi�;applicatian�`* En ig neer: s Name:{s) _- -��--4CA—CA-n I Mailing Address;.C/SJZ:.... ..... ... .. .... .... .. ..... tell Phone: j` � 2 a { ............ �� � L nd Line:: Ema_iI: _. j Contact:Peeson:..for Compliance in;regardsao.this project:. CeII Phone:.::... ... .. Land Line: ��� t 1 Email`: NOTES:.T_,:Alarm system::and associated:electrical_wor..:k must:be]nspected b�:a Town:approved electrical inspectic n:agency 2...We WIt no longer allow.systerris:to be.covered:urrti!<suet :time`as:an:as-built:plan'is reserved acid approved.The: iinstalled:systern:must match the.septic layoufi on;file---,no exceptions. 3.As built' ravings musfi:be submitted prior to the,inspection, if there has;beeri.a change t o<tha.:subrrtitted plans:4, Ifj for:aoy"reasan;.thotuilding permit application is-withdrawn,30°�:t f:th..1 s:retained:.bythe ToMi.'of tWeens6ury. After 1 year from the initial:application.date, 1001 of the fees retalried:.. Declaration: Any permit:.or approval.granted:Which:is based.:upon_or sgranted.in reliance;upona;ny'material representation or failu�eto.make a material fact.orcircumstance known by'or.crri behalf of an':applicant;shall be void;;F have:read:the regulations and:ag" tQ abide bVthese and all requirements of the Town of Qiaeensb' Sanitary.Sewage:Disposal.Qrdinance .. ... ..:: . . ` .:PRINT NAME:: CAvn, e ::SiGNATU.RE:.:._:.. . _... DATE: ::.... . ..: Septic Application ReVlsed.Decerhber2620 (awTOWN OF OUEENSBURY 742 Bay Road, Queensbury, NY. 12804-5902 Septic System Checklist lan to scale VI— q�Steceived 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) —$,AII wells on property and adjacent properties shown M N vcrl Water line shown Municipal or well 10'separation to any part of system VP/r( �cL J • l etback to property lines show 10' or more for any part of system 'f: 'Veptic tank and pump stations 10'from foundation 50'from any well/lake/wetland 10'from any waterline C-ASeptic 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) u-CLSeptic tank sized for number of bedrooms and add 250 gals for Jacuzzi tubs/garbage grinder each (47 a/,- Leech Field 20'from foundation 100'from any well 10'from water line r- —Seepage pit 150'from well 50'from septic tank rJ Seepage Pits 3-times diameter apart t 'Septic tank and pump stations over 30 gallons 50'from watercourse or wetland 1` distance from bottom of trench or system 24"to bedrock or mottling 36"within 1000'of Lake George Q-fg%Aeech field 100'from watercourse or wetland qe,-:)Toe of mound or bottom of retaining wall 1��0'from property line 100'from well 20'from Foundation Provide Engineer/Architect stamp for bed or design systems f-SADepartment of Health Approval for all mobile home park new systems Flood Plain requirements l�y 2' above established flood elevation to bottom of system f10 All tanks anchored or 2' above flood elevation Revised 4/15/2021 0 0 • oo o o MEMO OMEN CO�■■C' O CEE■ CCCCCCE CEC H �■C:C CaC CCCCOC .Cl/CC���N..0 v' OMEN , NNES... iCCM OEE■■■■OM .MH H ■ , Elm AY CC ..C.�„.. .CC.'.... .�u.'n: in 11■.■■■■. nR � . 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