SEP-0110-2023 SEPTIC DISPOSAL PERMIT office Use only
APPLICATION. Permi##: SG07 -:.u 11 P:
Town cfQuecns6ury
Permit Fee:$
Invoice#: . .
742 Bay Road,Que6ns,ur;NY 12804"
P:518-1614256 wvvw.pueensb'ury:ne't Septic Valiance. No .
Flood Zone? o
Wetlands? p Reviewed By:.
Project:Locatior+:."454 Bay Road;"Queensbury, NY
LP
:Tax Map#: 206.16-1=12-, . :.
�R 7 208
RESIDENCE INFORMATION:: . . _ TOWN OF QUEENSI3URY
Year Built Gallons #.of bedrooms: " .I gallolis per =total.dailY:flow, :BUILDING&CQI� S
per day bedroorri: Garbage Grin er. _ es" No"
1980:6rolder i50 Installed?. "(choose one) . -� x❑
1981-1991" 130 'Spa or.Hot Tub Yes, :No.
1992=Present 110
Installed? (choose one): E x❑
2 1.10.. : 220.. .
:PARCEL INFORMATION: :
Topography :D Flat;Rolling E]:Steep:Slope : 5 % $lope
"Soil-Nature O Sand O Loa_m ❑� Clay .. D Other;"explain:
Loamy".clay
:Groundwater.. 'At what depth?. 24 in
Bedrock/Impervious.mate.rial Ai What depth?".:N/A "
Domestic Water Supply _ 0■ .Municipal 01Nell Lake
(if well or lake; water supply from any:septic system absorption.is" "
Percolation Test Rate:"13.75 per:minute"per"inch (test"to be completed by"a
licensed.engineer/architect)"
PROPOSED"SYSTEM*INFORMATION:
Tank size. . :1500 : gallons (min..site-1;000 gallons; add 250 gallons for each:garbage cylinder or
spa/hot tub. .
System. Absorption w/#2 stone. Total length 1"38. .-ft.; _Each.Trench .46 ft..::
Seepage"Pit*/#3.stone. . How.many:. : . : . ; Size:;
Alternative.System:. Bed.or other.fype
Holding Ta"nk System Total required.capacity?. tank
. -
# of tanks
Septic Application Revised July 2022
M1;R-16-2023 22:50 FROM:VAUTRIN 6314999629 TO:15187610513 P.1/1
C;0nI1ACT lhit"QlRM61IQb PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
s li nt:
Name(s); Rocco Musumeci
Mailing Address, C/S/Z: 170 warren_$[,Glen$Falls, 12WI
Cell Phone: 516-993.8795 Land Line:
Email; rockLmoozeeverizon.net
� IPI
primary Qwnedsi:
Name(s): GeoMW Mir Corp.
G_
Mailing Address, C/S/Z: M warren$l,Glans Falls,12801
Cell Phone: Land Line:
Email: rockyr_ ozeQverizon.net
[] Check If all work will be performed by property owner ®nl
• Contractor:
Contact Name(S): TBDe
Contractor Trade:
Bailing Address, C/S/Z:
Cell Phone: Land Line:
Email:
*Workers' Camp documentation must be submitted with this aPR11cat�aon**
• En ineerr s
Name(s), SIZA Engineers
Mailing Address,C/S/Z; 463 Dixon Rd.Ste,7, Bldg,3, Queensbury,NY, 12804
Cell Phone: 518-761-0417 ex.21 Land Line:.
Email: odks@sraengineers.com
Contact Person for Compliance in regards to this project: Rocco Musumeci
cell Phone: 516-993-8798 Land Line:
.Email: rockyrndoze@verixon.het
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 Q,ueensbury Sanitary Sewage Disposal Ordinance,
PRINT NAME,. Rocco Musurnecl
SIGNATURE: �c��.�� DATE:-� �G/-2j
Sanlir AnNTf9,H0%1% �awbzuA� �v sff79
TOWN OF QUEENSBURY
742 Bay Road, Queensbury, 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 Jf Pp roved or En ineer unapproved Engineers and Architects
9
�J
All wells on property and adjacent properties shown �AUl,\c
ater line shown Municipal or well 10'separation to any part of system
T�W
Y.
t—Aetback to property lines show 10'or more for any part of system
S Septic tank and pump stations 10'from foundation, 50'from any well/lake/wetland, 10'from any waterline
�kseptic 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
SLeech Field 20'from foundation 100'from any well 10'from water line
M Seepage pit.150'from well 50'from septic tank
Seepage Pits 3-times diameter apart.
15 Septic tank and pump stations over 30 gallons 50'from watercourse or wetland
1 S Distance from bottom of trench.or system 24"to bedrock.or mottling 36"within 1000'.of Lake George
1
" Leech field 100'from watercourse or wetland
r4/- A_Toe of.mound or bottom.of retaining wall 10'from property line, 100'from we11,'20'from foundation
cS Provide Engineer/Architect stamp'for bed or design systems
- 4. Department of Health.Approval for all mobile home park new systems Flood Plain requirements
'J0 2' above established flood elevationto bottom of system
,A/ All tanks anchored or 2' above flood elevation
v Evergreen Professional Park -
D 453 Dixon Road,Ste.7,Bldg.3
NSPA [APR:52(02.3 Queensbury,NY 12804
P 518-761-0417 F 518-761-0513
ENGINEERS w.
TOWN OF QUEENSBURY
BUILDING&CODES
Town of Queensbury April 5, 2023
Buildings & Codes Enforcement SRA Job#23-076
742 Bay Road
Queensbury, NY 12804
ATTN: John O'Brien, Buildings & Code Enforcement'Director
VIA: email at JohnO(a)-gueensbury.net
RE: Musumeci Septic Replacement Design Record Drawing-454 Bay Road, Queensbury,
NY 12804 (Tax ID 296.16-1-1.2)
Dear Mr. O'Brien:
SRA Engineers has completed its inspections of the replacement septic system and site related
components for the above referenced project. Inspections were.completed during the course of
the construction at appropriate_times to sufficiently inspect the work. To the best of our
.knowledge, information, and belief, the work was constructed in general conformance with the
project drawings that were reviewed and approved during the permitting process, with the
exception of minor changes that are documented on the attached Record Drawing for the
project. These minor changes do not affect the compliance or function of the system.
Please feel free-to contact me with any questions.
Sincerely,
Erik C.F. Sandblom, PE
Principal
Enclosure: Record Drawing
Cc: Mark Smith, Queensbury Code Enforcement
Rocco Musumeci
N 0� av •
�O p�NG &
Bw`ewed