SEP-0128-2021 ,; , SEPTIC DISPOSAL PERMIT office Use only
APPLICATION Permit#: Cr. 1 •Z�ti2�-?�2�
r°`""°f(Queens ry Permit Fee: $
742 Bay Road,Queensbury,NY 12 3C
Invoice#:
P:518-761-8256 www.caueensbumb Flood Zone? Y - N Reviewed By:
MAR 19 2021
TOWN OF QUEENSBURY
Project Locationt 625 ODES
Tax Map #: 278.19-1-14
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)
1981-1991 130 Spa or Hot Tub Yes No
1992-Present 110 3 110 330 Installed? (choose one)
PARCEL INFORMATION:
Topography Fla Rolling Steep Slope 3-10 % Slope
Soil'Natur.e Sand Loam Clay Other, explain:
Groundwater At what depth? greater than 72"
Bedrock/Impervious material At what depth? greaterthan 72"
Domestic Water Supply Municipal Well Lake
(if well or lake, water supply from any septic system absorption is
ft.)
Percolation Test Rate: 1:05 per minute per inch (test to be completed by a
licensed engineer/architect)
PROPOSED SYSTEM INFORMATION:
Tank size 1,000 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: Bed- 15'x 30'=450'
Holding Tank System Total required capacity? ; tank size ;
# of tanks
Septic Application Revised January 2021
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicint:W,�-�.
Name(s): James Bombard,.Jr: "! a
Mailing Address, C/S/Z: 625 Moon Hill Rd
a _
Cell Phone: Land Line: Ce11-S18-361-0167
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 Service
Contractor Trade: Installation
Mailing Address, C/S/Z: 144 Luzerne Rd, Queensbury, NY 12804
Cell Phone: Land Line:518-792-7257
Email:
**Workers' Comp documentation must be submitted with this application**
• Engineer(s)•
Name(s): Hutchins Engineering PLLC
Mailing Address, C/S/Z: 169 Haviland Road Queensbury, NY 12804
Cell Phone: Land Line: 518-745-0307
Email:thutchins@hutchinsengineering.com
Contact Person for Compliance in regards to this project: James Bombard/George Drellos/Tom Hutchins
Cell Phone: Land Line: Cell 518-361-0167
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 agree to abide.by these and all requirements of the Town of Queensbury
Sanitary Sewage Disposal Ordinance.
PRINT NAME:G. om H in , P.E.
SIGNATURE: DATE: 3/18/21
Septic Application Revised January 2021
1
TO OF ®UEENSB .��
742 Bay Road, Queensbury, NY. 72804-5902
q_?__C-�-Plan to scale Septic System Checklist
Received Deep hole perc test results from engineer/Architect if a.pplica.ble QTown Approved
(Engineers and Arch tects)pone 30 to AprrH 15 Town Epoginger for unapproved Engineers and ArrCbRercts)
All wells on property and adjacent properties shown
L/T�_Water line shown(Municipal or well 10'separation to any part of system
�Setbackto property lines show 10'or more for any part of system
yL°� Septic tank and pump stations 10'from foundation 50'from any well/(ake/wetland 10'from;a,ny
waterline
4'sJ .Sleptic tank to foundation crawl,space/slab on grade,grade in crawl space must be above top of
eptic 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
blej Leech Field 2.0'from foundation 100'from any well 10'from water line
�Tg Seepage pit 150'from well 501 from septic.tank
Seepage Pits 3-times diameter apart
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
��Leech field 100'frorn watercourse or wetland
Toe of mound or bottom of'retaini.ngwall 10'from property line 100'from well 20'from
Foundation
Provide Engineer/Architect stamp for bed,or design systems
w 16 bepairtment of Health Approval for all mobile home park new systems
Flood Plain requirements
..JZ)2'above established flood elevation to bottom of system
r� . AIJ tanks anchored or 2' above,flood elevation
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" Name of Natttral Be,•auty ... A Good ,Place to Live "