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SEP-0072-2023 f SEPTIC DISPOSAL PERMIT office Use Only _ APPLICATION Permit#: 7oum of t'jucensbury Permit Fee:$ Invoice#: �i�'7 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.gueensbury.net Septic Variance? Flood Zone?)+-.) 0--�—D— Wetlands? M Reviewed B Project Location: K ®rive IE 9 W E D Tax Map #: 30 l . 3 —2: - 2. FEDD 2 3 2023 RESIDENCE INFORMATION: TOWN OF QUEENSSURY Year Built Gallons #of bedrooms: X gallons per =total daily flow BUILDING CODES per day bedroom Garbage Grinder Yes No 1980 or older 150 3 I10 33 a Installed? (choose one) ❑ 1981-1991 130 Spa or Hot Tub Yes No 1992-Present 110 Installed? (choose one) El PARCEL INFORMATION: Topography [vKlat Rolling ❑ Steep Slope % Slope Soil Nature and ❑ 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: per minute per inch (test to be completed by a licensed engineer/architect) PROPOSED SYSTEM INFORMATION: Tank size l000 gallons (min. size 1,000 gallons, add 250 gallons for each garbage cylinder or spa/hot tub . To•,K -L System Absorption field w/#2 stone Total'length Wyo ft.; Each Trench 6 o ft. Lo© � kjq 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 July 2022 CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL • Applicant: Name(s): TBS Sepf�c m nr9�„ Mailing Address, C/S/Z: 2 Go~ "rm- ft 49$3; w} Cell Phone: P%- '7 y 6"o $S 6 Land Line: rt%- 79 g_ SI4 y Email: f S4:o/e!, 9 r bs5-001--c •�o.. • Primary Owner(s): n Name(s): Mg-E•YAew ID • pes rho Mailing Address, C/S/Z: Zct gr*-,K give W k wr /7134-1 Cell Phone: SA-746-51� 4 Land Line: Email: ❑ Check if all work will be performed by property owner only • Contractor: Contact Name(s): 'Tef SPn J.c t Contractor Trade: QlL-n, b,;5 4 '7,r,�/j Mailing Address, C/S/Z: 2 L®wov w•rr�r•�t Q�l ar Cell Phone: S-do—"7 Wo-Dgs 6 Land Line: 1-1$— 7ft—tR y Email: efLotey 'Z i bSr�v/;r•<o.. "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: Cell Phone: Land Line: Email: 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: z IQ t c s� �n � �e v SIGNATURE: "(/' DATE: Septic Application Revised July 2022 TO'f _ OF QUEENSBURY 742 Bay Road, Queensbuq, NY. 12804-5902 Septic System Checklist Plan to scale 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) All wells on property and adjacent properties shown V- 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 16eptic tank and pump stations 10'from foundation 50'from any well/lake/wetland 10'from any waterline 0-6septic 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 ' ASeepage pit 150'from well 50'from septic tank -e6seepage Pits 3-times diameter apart Septic tank and pump stations over 30 gallons 50'from watercourse or wetland t(�distance from bottom of trench or system 24"to bedrock or mottling 36"within 1000'of Lake George MLeech field 100'from watercourse or wetland I4-Toe of mound or bottom of retaining wall 10'from.property line 100'from well 20'from Foundation Provide Engineer/Architect stamp for-bed or design systems �JDepartment of Health Approval for all mobile home park new systems Flood-Plain requirements .N"2' above established flood elevation to bottom of system �-DAII tanks anchored or 2' above flood elevation P.:,,46M en VI)MI • . . , . ,::::,■C:C:n, :■uiMEN :::mom O::: MINE �' ■' eio° ' �' �$r. � !: „ :::,■:,■ , ■ni,■■ :,i„ .', �•, r O■■u■■■■■■■n _ nr. a■r ■i■: Eu am mo _- ■■� .- NOON .-- • •- �- f. •- .. 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