SEP-0077-2023 - SEPTIC DISPOSAL PERMIT office use only
APPLICATION Permit#:'
Town ofQueensbury 8 Permit Fee:$
Invoice#: ���
742 Bay Road,Queensbury,IVY 12804
P:518-761-8256 www.aueensbury.net Septic Variance.
Flood Zone?,'V,_..1 r
Wetlands? ��_ Reviewed
I
Project Location: y,5 Z�•-�G-s �1:
E9W
Tax Map #: l
FEB 2 7 2023
RESIDENCE INFORMATION: wN of QUEENSBURY
Year Built Gallons #of bedrooms: X gallons per =total daily flo
per day bedroom kage C ' r Yes No
1980 or older 150 Installed? (choose one) ❑ 91
1981-1991 130 Spa or Hot Tub Yes No
1992-Present 110 1 J Installed? (choose one) ❑
PARCEL INFORMATION:
Topography Flat Rolling ❑ Steep Slope % Slope
Soil Nature (Sand ❑ Loam ❑ Clay ❑ Other, explain:
Groundwater At what depth? A100te
Bedrock/Impervious material At what depth?
Domestic Water Supply (-Municipal ❑ Well ❑Lake
(if well or lake, water supply from any septic system absorption is
Percolation Test Rate: per minute per inch (test to be completed by a
licensed engineer/architect)
PROPOSED SYSTEM INFORMATION:
Tank size ,Doc gallons (min. size 1,000 gallons, add 250 gallons for each garbage cylinder or
spa/hot tub J rkt,4 ml,9.
System Absorption field w/#t-stom Total length /Jr ' 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
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): Lg;�0, r,
Mailing Address, C/S/Z: `
Cell Phone: 237Z-47o`7 Land Line:
Email: d"I,�,S`7'or, a c2c1,�S�f-'���s • Go
• Primary wn r s
1
Name(s): `c o e -om ,O/'
Mailing Address, C/S/Z: k52.
�sb.�✓'7��" r�S°
Cell Phone: � �'--J a7 132y° Land Line:
Email: micLi•%s �`.va.'7 �y�.tia�•r.�,,.
❑ Check if all work will be performed by property owner only
• Contractor: rr
Contact Name(s):
Contractor Trade: 1r;
Mailing Address, C/S/Z: 0 t. ® �u•��y�j
Cell Phone: / r 9-120 Land Line: 7*S,.i� —/cn
Email: e� i�c C •Cosy^
**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: YZIZ-,,47 D7 Land Line:
r.
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: etr �rrcc.. ,
SIGNATURE: DATE: 7' V
TOW,;' aF QUEENSB URY
-742 Bay Road, Queensbury, NY. 12804-5902
Septic System Checklist
IW Plan to scale
t_Re'ceived 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
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
Septic tank and pump stations 10'from foundation 50'from any well/lake/wetland 10,from any waterline
)�lkSeptic 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 lacuizi tubs/garbage grindeneach
Leech Field 20'from foundation 100'from any well 10'from water line
Seepage pit 150'from well 50'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'from watercourse orwetland
'foe 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
N�Department of Health Approval for all mobile home park new systems Flood Plain requirements
2'above established flood elevation to bottom of system
r v All tanks anchored or 2'above flood elevation
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