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SEP-0083-2023 SEPTIC DISPOSAL PERMIT office use only APPLICATION Permit#: 5Gf-'O®L3 20-2-2-�> Tosco of Qucensbun © / Permit Fee:$ C7 Invoice#: _ 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.gueensbury.net Septic Varianc ? NO Flood Zone? . N(; Wetlands? wz Reviewed By: Project Location: 4 eve Tax Map #: MAR 0 3 202� RESIDENCE INFORMATION: Year Built Gallons #of bedrooms: X gallons per =total daily flow TOQ1 III WN 9F QUEENS�URY per day bedroom Lftrb��ilfteZ.—'-uL)t_b Yes No 1980 or older 150 5 "Jr�d f���j Installed? (choose one) ❑ 9 1981-1991 130 Spa or Hot Tub Yes No 1992-Present 1110 - Installed? (choose one) ❑ PARCEL INFORMATION: Topography ® Flat Rolling [] Steep Slope % Slope Soil Nature ]Sand ❑ Loam ❑ Clay ❑ Other, explain: Groundwater At what depth? Bedrock/Impervious material At what depth? Domestic Water Supply X 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 Z&-X) gallons (min. size 1,000 gallons, add 250 gallons for each garbage cylinder or spa/hot tub 19 Z_ 60 V- 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: 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): /�oc��,4 Sk-rl�o�citiv�l Mailing Address, C/S/Z: 5-9 131c,,,L- �J-- �- Cell Phone: qoq? Land Line: Email: 1.-Q iv%vr,.-, • Primary Owner(s)• Name(s): Ra «,;C, Mailing Address, C/S/Z: 4-V c�r^es0-A-C Cell Phone: yog - 4 171 Land Line: Email: N g,.\ ❑ Check if all work will be performed by property owner only • Contractor: Contact Name(s): Contractor Trade: Mailing Address, C/S/Z: Cell Phone: Land Line: Email: **Workers' Comp documentation must be submitted with this application** • Enaineer(s)• Name(s): Mailing Address, C/S/Z: Cell Phone: Land Line: Email: Contact Pers ZforConmpliance in regards to this project: -k 2U1-- h Cell Pho 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: SIGNATURE: DATE: S x,? Septic Application Revised July 2022 TOWN OF QUEENSBURY 742 Bay Road, Queensbury, NY. 12804-5902 Septic System Checklist yL� Plan to scale N d Received Deep hole pert test results from engineer/Architect if applicable(Town Approved Engineers and Architects;June 30 to April 15 Town Engineer for unapproved Engineers and Architects) R I rcAll wells on property and adjacent properties shown / �� /I �j(��,. JOPP/I . p p Y J p p 1'�G h�.G� ri/ �1sater line shown Municipal or well 10'separation to any part of system Ylf-4 tback to property lines show 10'or more for any part of system eptic tank and pump stations 10'from foundation 50'from any well/lake/wetland 1q'from any waterii e �x'(54 l " gp¢le t n L s, JASeptic tank to foundation crawl space/slab on grade,grade in crawl space must be aboWtop 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 4tseepage pit 150'from well 50'from septic tank *Seepage Pits 3-times diameter apart eptic 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 Cur, � Wr-zwk -Ceech field 100'from watercourse or wetland (/ Toe of mound or bottom of retaining wall 10'from property line 100'from well 20'from Foundation 4Provide Engineer/Architect stamp for bed or design systems Department of Health Approval for all mobile home park new systems Flood Plain requirements /V-6 2'above established flood elevation to bottom of system r'J6 All tanks anchored or 2' above flood elevation Mark Smith From: Lou DeRidder <lou@morningstarseptic:com> Sent: Tuesday, March 7,2023 1:14 PM To: Mark Smith Subject: 6 Hillcrest Mark, The owner is not sure on all the water fixtures so we will have to use the 150 gallon per day..Sorry I missed it. Thank you Lou DeRidder Morningstar Excavation and Septic, LLC This is an external ernail. ■• not click links or ••- attachments unless you recognize the sender and know the content is safe.