SEP-0820-2021 SEPTIC DISPOSAL PERMIT office Use only
j APPLICATION Permit#: �P-062D -?�Ll
Town of Qucen Gas ry
Permit Fee:$
Invoice#: '1��✓
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.4ueensburv.net Flood Zone? Y O Reviewed By:
Project Location: 54 WESTERN AVENUE
Tax Map #: 302.191-30TOKp� OF
_
RESIDENCE INFORMATION: -.
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) X
1981-1991 130 Spa or Hot Tub Yes No
1992-Present 110 2 (EX) + 1(F) =3 110 330 Installed? (choose one) X
PARCEL INFORMATION:
Topography ✓ Flat Rolling Steep Slope % Slope
Soil Nature VSand Loam Clay Other, explain:
Groundwater At what depth? GREATER THAN 6 FT
Bedrock/Impervious material At what depth? GREATER THAN 6 FT
Domestic Water Supply Municipal Well Lake
(if well or lake, water supply from any septic system absorption is
ft.)
Percolation Test Rate: 1-5MIN 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 EX: 1000 GAL CONCRETE
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 FT X 25 FT
Holding Tank System Total required capacity? ; tank size ;
# of tanks
Septic Application Revised Janua
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): ROGER LANGWORTHY
Mailing Address, C/S/Z: 54 WESTERN AVENUE. QUEENSBURY,NY 12804
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):SANITARY SEWER SERVICES
Contractor Trade:
Mailing Address, C/S/Z:LUZERNE RD, QUEENSBURY
Cell Phone: Land Line:518-796-3760
Email:
"Workers' Comp documentation must be submitted with this application"
• Engineer(s):
Name(s): CENTER PROJECT SERVICES
Mailing Address, C/S/Z:73 SHERIDAN STREET, GLENS FALLS NY 12801
Cell Phone: Land Line:
Email:
Contact Person for Compliance in regards to this project: GEORGE DRELLOS
Cell Phone: Land Line: 518-796-3760
Email:
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 agr abide by these and all requirements of the Town of Queensbury
Sanitary Sewage Disposal Ordinance
PRINT NAME:GEORGE DRELLOS
SIGNATURE:
DATE:
Septic Application Ra,,;�o� i,,,,,,")ml
TOWN OF QUEENSBURY
742 Bay Road, Queensbury, NY. 12804-5902
Septic System Checklist
�.S 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)
-�AII wells on property and adjacent properties shown
' -Water line shown Municipal or well 10'separation to any part of system
�'Q,-S Setback to property lines show 10' or more for any part of system
�tLJ—Septic tank and pump stations 10'from foundation 50'from any well/lake/wetland 10'from any waterline
N*Septic 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)
Z�jSeptic tank sized for number of bedrooms and add 250 gals for Jacuzzi tubs/garbage grinder each
I-t�5 Leech Field 20'from foundation 100'-from any well 10'from water line
rf�Seepage pit 150'from well 50'from septic tank
Seepage Pits 3-times diameter apart
CJY,d 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
�j Leech field 100'.from watercourse or wetland
e aining wa from property line 100'from well 20'from
Foundation
Provide Engineer/Architect stamp for bed or design systems
Department of Health Approval for all mobile home park new systems Flood Plain requirements
r.J 0 2' above established flood elevation to bottom of system
/,J 6 All tanks anchored or 2' above flood elevation
rig. �
Revised 4/15/2021