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SEP-0203-2023 SEPTIC DISPOSAL PERMIT office use Only
APPLICATION Permit#:
Town ofQac n b ry Permit Fee:$ �5
Invoice#:
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.gueensbury.net Septic Variance? Y O
Flood Zone? Y G
Wetlands? Y (l Reviewed By:
Project Location: I ( y ---3rp,
Tax Map #: �� • � — � — �� � � _ �-----�K,�n.�.��
MAY
RESIDENCE INFORMATION: F ,��I E��F,F;U'R
TOWCCZ
Year Built Gallons #of bedrooms: X gallons per =total daily flow IL�J4i'RO _�,0D,-'-
BU
per day bedroom Garbage Grinder Yes No
1980 or older 150 Installed? (choose one) ❑ M
1981-1991 130 Spa or Hot Tub Yes No
1992-Present 110 �� .., 1 �� ��
Installed? (choose one) ❑
PARCEL INFORMATION:
Topography Flat Rolling ❑ Steep Slope % Slope
Soil Nature Sand ❑ Loam ❑ day ❑ Other, explain:
Groundwater At what depth? ��
Bedrock/Impervious material At what depth?
Domestic Water Supply 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 gallons (min. size 1,000 gallons, add 250 gallons for each garbage cylinder or
spa/hot tub �5-a P_ T
System Absorption field w/#2 stone I 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): MiA� ©1J
Mailing Address, C/S/Z:
Cell Phone: Land Line: .
Email: a .QDVV\
• Primary Owners :t�
Name(s): PK
�a
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):
Contractor Trade: 11e 0 i2+�
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email:
"Workers' Comp documentation must be submitted with this application"
• Engineer(s)•
Name(s): 2L)&
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email:
Contact Person for Compliance in regards to this project:, 'A UJ�q AJ
Cell Phone: �1 "VS70SS 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: r�''�3
Septic Application Revised July 2022
TOWN OF QUEENSBURY
742 Bay Road, Queensbury, NY. 12804-5902
- Septic System Checklist
Plan to scale
AReceived Deep hole perc test results from engineer/Architect if applicable(Town Approved Engineers, Jan
Architects;June 30 to April 15 Town Engineer for unapproved Engineers and Architects)
t-Jb All wells on property and adjacent properties shown ftkUyl10\p l
Waterline shown Municipal or well 10'separation to any part of system
U
Setback to property lines show 10'or more for any part of system
(/Cj'//Septic tank and pump stations 10'from foundation, 50'from any well/lake/wetland, 10'from any waterline
4septic 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
Leech Field 20'from foundation 100'from any well 10'from water line
i ASeepage pit 150'from well 50'from septic tank
^/Seepage Pits 3-times diameter apartSeptic 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 or wetland
'�JkToe of mound or bottom of retaining wall 10'from property line, 100'from well, 20'from foundation
6�_<J Provide Engineer/Architect stamp ems
V "epartment of Health Approval for all mobile home park new systems Flood Plain requirements
0 2' above established flood elevation to bottom of system
It/D All tanks anchored or 2' above flood elevation
Notice of Intent to Construct,
NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Community Environmental Health and Food Protection Enlarge'or Convert a Facility
Please read instructions on back before completing form.
r�1'K;� I
Proposed facility name: ...5`X ._..__.._._........--_..__ ..__.._.__......_..__........ .. ........JJ..11.......
_._._._.._. .. ......__....................._..__..__...___..-;: � " - ___--
g ,�
If existing,current ,`'facility name: _ `- �"' C .,.,...:..,_. ,.._.._ __.......�. _ ...._....,._. _.. . ,. Fla!
The property wilt be used as: ;J Food service establishment i I Agricultural fairground �5
-1 Temporary residence j, j Migra nt fa rmwo rker horisi n ENAt6 I
Children's camp ( Mobile home park V !
LJcampground i Swimming pool TOWS( Or
pg l.,_.i g p DUI!
-__ Mass gathering ;. . Bathing each
i w
._.._..._......-.-___
County--•' �'� _ -_-- Town,Villa g"City-
filew ! Renovation LJ Conversion Are plans attached? _ Yes No
Detailed location(e.g.,road,street,building n er, istapce fro well known po' 5 I'd
. ..._........-.
Name of owner: Address: Phone:( -) g
Name of operator: Address: Phone:( )
.._..__........_.._...__._...._.;. -- __....._.....�----..-_..._.................._.. ......._—._ _._...._..............._........._.._..._....-_...._._._................_._..._..-....._.--..--.--...'............_..........._.... _.-..._.._......._.--._.—.._...............
It is proposed to(describe in detail;use additional sheets if necessary):
5b 1 5��
1 The following permits or approvals for the proposed construction,enlargement or conversion have been applied for or received:
1
i
Name of local code enforcement officerfor facility location: Address: Phone:( )
Date:Signature: ti w.......... ..... .....- -..._. _......._._.:. .._........._ . ,.._._.,,_._... .,.__._....._........__...._...:.- _w_...__.__........_...-...._._..__
Title: _._ ; Owner (.._._ Operator __; Other,.specify
Mailing Ad ress: Phone:(
DOH-154(4104)Page 1 of 2 �` (GEN-140)
•
•
s
x.
aIr
•
� �
s
DESIGN DATA:
DESIGN FLOW = •700 GPD FOR TWO UNITS W/ THREE BEDROOMS EACH (6 BR TOTAL)
NEW'"STANDARD FIXTURES, (1.6 GPF & 3 GPM MAX.)
AN ELGIN SYSTEM IS PROPOSED AS A SUBSTITUTION TO PREVIOUSLY APPROVED
SEEPAGE PITS
1-5 MINUTE PERCOLATION RATE W/ APP RATE OF 1.7 G/SF
8 OUTLET DBOX W/ SPEED LEVELERS ROWS OF 7
1750 GALL DC TANK
-n
2 BR DOUBLE
WIDE. M08ILE
HOME
70'
'A
28'
I
RKINGI24'X20'
I 'm
I
c�
z CONSTRUCT SWALE
BETWEEN DOUBLE
WIDE HOMES, GRADE
SURFACE TO SWALE
70'
12'
28T
I
PARKINGI24'X20`
SHUT OFF — —
,- - ACCESS ROAD B
based 01I ours is s all 11%dficatlans
with our CO he plans and s tI1ldln Codes u
ltidtCalti CC IIIIII 111C
New Yatk State. — — — —
PLAN DOUBLE WIDE LOT
SCALE 1" = 20'
GRADE SURFACE
TOWARDS THE SWALE
o
I
SHUT OFF
NEW YORK STATE
LENS F—AL
12'-0" -
�-N--IN-SITU
SWALE CROSS SECTION
SCALE: 1/2" = 1
Dated: Iv,a
ans #E�r: s-12" TOPSOIL
These p;
WHITE —
ANTI-SILTX
FABRIC
are I—elly Q,ccePie �. B43 ELGIN MAT
Reviewed by'
forhe-0 (;ommiss onr of Hcalit
iWj'c trlil'/�`� ft1�F.iCt f tll HIAI III
RNS I -Al' .5 F>1 TI't1("I't7i'I'I,`t
i
LOTS ORIGINALLY APPI
) FOR SINGLE WIDE HOMES,
CALCULATE ADDITIONA
I
DOFF FOR DOUBLE WIDEHOMESAND
SIZE SHALLOW S1
RAIN INTENSITY i-=2" I
IOUR FOR 100 YEAR STORM
ADDITIONAL AREA FOR
WIDE: 980 SF / UNIT X 2
1960 SF
TIME = 1 HR
RUNOFF: 2" X 1960SF
53 CF (100 YR STORM)
STORAGE CAPACITY OF
_E IS 7 SF/FT X 55' = 385 CF.
TIME FOR FULL SWALE
RAIN AT, 5 MIN / IN IS 1 HOUR
FOR A 12" DEEP SWAL
APPENDIX 75A SETBACK
TREATMENT AREA TO PRi
TREATMENT AREA TO RE!
SEPTIC TANK TO WATER
LACES;
Y LINE: 10'
:E: 20'
Y. 50'
4,,
1--\�N-SITU SAND
GENERAL NOTES:
1. DESIGN AND ALL WORK FOR TREATMENT SYSTEN
PER NYSHD APPENDIX 75-A
2. ALL ROOF OR HOUSE DISCHARGES SHALL BE
DIRECTED AWAY FROM THE TREATMENT AREA.
3. OWNER/CONTRACTOR RESPONSIBLE FOR
I
ASBUILT SKETCH OF ACTUAL LOCATION OF
COMPONENTS.
.� I < <
4. PRIOR TO EXCAVATING CONTACT LAYS DIGSAFE A
<
1-800-962-7962.
S. PERCOLATION RATES TAKEN FROM APPROVED
SEEPAGE PIT DESIGN BY VDS, 3-16-93.
7. TREES AND ROOTS SHALL BE REMOVED IN
TREATMENT AREAS.
8. SEAL UNUSED INLETS OF SEPTIC TANK.
10. ALL COMPONENTS TO BE SET ON A LEVEL 12"
STONE BASE.-
'
11. D-BOX TO BE 8 OUTLET W/ SPEED LEVELERS,
CAULK OULTET SEALS.
12. SEPTIC TANK TO BE FM OR EQUAL W/ 4000 PR
CONCRETE AND 5-9% ENT. AIR
13. WATER SUPPLY IS MUNICIPAL.
GROUNDWATER OR IMPERVIOUS LAYER
ELGIN DETAIL
SCALE: 1/2" - 1'
mRv
Hartman < � as�t�glaf4Wn rr
LOCATION MAP SCALE: 1 " = 3 MILES
IT IS A VIOLATION OF THE LAW FOR ANY PERSON,
UNLESS ACTING UNDER THE DIRECTION OF THE
LICENSED ENGINEER, TO ALTER ANY ITEM OR
PORTION OF THIS DOCUMENT IN ANY WAY.
THE ENGINEER HAS NOT BEEN RETAINED TO
PERFORM OR PROVIDE INSPECTIONS OR
CERTIFICATIONS ASSOCIATED WITH THIS PROJECT.
IF IN THE COURSE OF THIS PROJECT A CONDITION
EXISTS WHICH DISAGREES WITH THAT AS
REPRESENTED ON THESE PLANS. THE CONTRACTOF
SHALL STOP WORK AND NOTIFY THE ENGINEER OR
ASSUME ALL RESPONSIBILITY ARISING THEREFROM.
IT IS THE RESPONSIBILITY OF THE
OWNER/CONTRACTOR TO ENSURE THAT ALL
MATERIAL ORDERED COMPLIES WITH PROJECT
REQUIREMENTS.
0
RYAN M. BURNS, NYS P.E. LICENSE No. 084062
DESTROY PREVIOUSLY DATED DRAWINGS
A° 1 12/14 RB ENG. COMMENTS
¢ NO. DATE I BY REVISIONS
UPSTATE DESIGN ASSOCIATES
RESIDENTIAL DESIGN AND CIVIL ENGINEERING
" RYAN M. BURNS, P.E. IRA S. ALTER, P.E.
180 PLEASANT STREET 10 MADELINE DRIVE
r Fae KEESEVILLE, NY 12944 SARATOGA SPRINGS NY
t9t P:518-572-0256 518-573-2549" 128E
,.Odt R 518-536-9058
QUEEN5BURY VILLAGE MHF
aynvt
PROJECT: ELGIN SEPTIC / RUNOFF DESIGN
LOCATION: PETRIE LANE, QUENSBURY NY
DATE: 10/10/07
DRN. BY RMB SHEET NO. 1
GENERAL NOTES:
)ESIGN DATA:
DESIGN FLOW=•700 GPD FOR TWO UNITS W/ THREE BEDROOMS EACH (6 BR TOTAL),
N ez, !STANDARD FIXTURES, 1.6 GPF & 3 GPM MAX.
AN ELGIN SYSTEM IS PROPOSED AS A SUBSTITUTION TO PREVIOUSLY APPROVED
SEEPAGE PITS
1-5 MINUTE PERCOLATION RATE W/ APP RATE OF 1.7 G/SF
(28) 843 ELGIN MATS REQ'D, (4) ROWS OF 7
8 OUTLET DBOX W/ SPEED LEVELERS
1750 GALL DC TANK
en
CD C
jjj r
CA
IV
C U
J 0,
v)
IZ rp
® C
°
ci6
in a rx
c9
BR DOUBLE0.
IDE MOBILE
[HOME
u�y
EM
CONSTRUCT SWALE
BETWEEN DOUBLE
WIDE HOMES,'GRADE
SURFACE TO SWALE
70'
0
1
N
12`
'o
28° � 28°
a- I I 7 1 I
PARKINGI24'X20' I' I PARKINGI24'X20° I ��
r
55.00'
SHUT OFF �t�i
I)F
'TO�NN OF Qt.1E.ENSB
U U)ING IPAITMEk (lance
Eased ()n OUr I,,,,,d EY8UIS08tlalla COm;) ACCESS ROAD B
with our camments�saInd $ edfic t onsu areaIII —
'IC1d0t' C e
lull compliance vJith
eta+gyp PLAN —DOUBLE WIDE LOT
I�B`,N YOf1 S.�,e SCALE 1" 20'
GRADE SURFACE
TOWARDS THE SCALE
a-
1
OFF
SEED
'—�N—SITU SAND --��
SWALE CROSS SEC710N
SCALE.1/2" = 1'
NEW YORK STATE
LENS FAL
Dated a
These plans
ere hereby A,cceo'
Reviewed by:
for the
MAY
i'J}'r� i)f:'�r1;� r�hil I�'i't)i• H!_Al 1•F1
� { t.l�1� f/i];t.S"()ISt•t'tIC"1`t)I�I�K'i� i
LOTS ORIGINALLY APPI
3 FOR SINGLE WIDE HOMES,
CALCULATE ADDITIONA
DOFF FOR DOUBLE WIDE HOMES
AND SIZE SHALLOW 51
RAIN INTENSITY :-=2" I
IOUR FOR 100 YEAR STORM
ADDITIONAL AREA. FOR
WIDE: 980 SF / UNIT X 2 =
1960 SF
TIME = 1 HR
RUNOFF: 2" X '1960SF
53 CF (100 YR STORM)
STORAGE CAPACITY OF
E IS 7 SF/FT X 55' = 385 CF.
TIME FOR FULL SWALE
RAIN AT, 5 MIN / IN IS 1 HOUR
FOR A 12" DEEP SWAL
APPENDIX 75A SETBACK !
NCES:
EATMENT AREA TO PRE
EATMENT AREA TO RE
F
Y LINE.10'
:E° 20'
PTICTANK TO WATER
"-�—IN—SITU SAND
GROUNDWATER OR IMPERVIOUS LAYER
ELGIN DETAIL
SCALE: 1/2" - 1'
9
1. DESIGN AND ALL WORK FOR TREATMENT SYSI
PER NYSHD APPENDIX 75-A
2. ALL ROOF OR HOUSE DISCHARGES SHALL BE
DIRECTED AWAY FROM THE TREATMENT AREA.
3. OWNER/CONTRACTOR RESPONSIBLE: FOR
ASBUILT SKETCH OF ACTUAL LOCATION OF
COMPONENTS.
4. ;PRIOR TO EXCAVATING CONTACT NYS DIGSAFI
1=800-962-7962.
5. `PERCOLATION RATES TAKEN FROM APPROVE[
SEEPAGE PIT DESIGN BY VDS, 3-16-93.
7. TREES AND ROOTS SHALL BE REMOVED IN
�"TF EATMENT AREAS.
8.+ SEAL UNUSED INLETS OF SEPTIC TANK.
16. ALL COMPONENTS TO BE SET ON A LEVEL 1
S ONE BASE.
1 D—BOX TO BE 8 OUTLET W/ SPEED LEVELEI
CQ,ULK OULTET SEALS.
12. SEPTIC TANK TO BE FM OR EQUAL W/ 4000
CONCRETE AND 5-9% ENT. AIR
13. WATER SUPPLY IS MUNICIPAL.
IT IS A VIOLATION OF THE LAW FOR ANY PERSON
UNLESS ACTING UNDER THE DIRECTION OF THE
LICENSED ENGINEER, TO ALTER ANY ITEM OR
PORTION OF THIS DOCUMENT IN ANY WAY.
THE ENGINEER HAS NOT BEEN RETAINED TO
PERFORM OR PROVIDE INSPECTIONS OR
CERTIFICATIONS ASSOCIATED WITH THIS PROJEC'
IF IN THE COURSE OF THIS PROJECT A CONDITIC
EXISTS WHICH DISAGREES WITH THAT AS
REPRESENTED ON THESE PLANS. THE CONTRACI
SHALL STOP WORK AND NOTIFY THE ENGINEER C
ASSUME ALL RESPONSIBILITY ARISING THEREFRf
IT IS THE RESPONSIBILITY OF THE
OWNER/CONTRACTOR TO ENSURE THAT ALL
MATERIAL ORDERED COMPLIES WITH PROJECT
REQUIREMENTS.
RYAN M. BURNS, NYS P.E. LICENSE No. 084062
DESTROY PREVIOUSLY DATED DRAWINGS
i€ t "r" 41E
1
1 12/14
RB
ENG. COMMENTS
N0.
DATE
BY
REVISIONS
UPSTATE DESIGN ASSOCIATES
actin 1
s
RESIDENTIAL DESIGN AND CIVIL ENGINEERING
RYAN M. BURNS, P.E. IRA S. ADLER P.E.
180 PLEASANT STREET 10 MADELINE DRIVE
Hartman : C' rii. "'
a
KEESEVILLE, NY 12944 SARATOGA SPRINGS
P: 518-572-0256 518-573-2549 12
banivlaeayan P,
cnr S� r"
Fe waodr
I g
F 518-536-9058
QUEENSBURY VILLAGE M.
tfIQ , , ; •I
M y
> ( : R
! Rayno!'
®
rn. ..
PROJECT: ELGIN SEPTIC RUNOFF DESK
LOCATION: PETRIE LANE, QUENSBURY NY
LOCATION MAP SCALE: 1 " = 3 MILES
DATE: 10/10/07
DRN. BY: RMB SHEET NO. —
DE, GN FLOW � -700 GPD FOR TWO UNITS W/ THREE BEDROOMS EACH (6 EIR TOTAL)
NEW%ANDARD FIXTURES. (1.6 GPF & 3 GPM MAX.)
AN ELGIN SYSTEM IS PROPOSED AS A SUBSTITUTION TO PREVIOUSLY APPROVED
SEEPAGE PITS
-5 MINUTE PERCOLATION RATE W/ APP RATE OF 1.7 G/SF
(28) B43 ELGIN MATS REQ'b. (4) ROWS OF 7
8 OUTLET DBOX W/ SPEED LEVELERS
1, 750 GALL DC TANK
10
\NG
\w 6
\0\0 hat mot dMr-allul-
s 0 code
'aim mmo\ks
I oo G e V\�AiSkj the
5\c e
'10 11
cO
of
10
13'-
0
C
c:
1,
ca
2 BR DOUBLE z
0
WIDE MOBILE i
HOME to
70'
12'
0,
<VIG124`*X20' I T"�,
r_
13'-6"-
CONSTRUCT SWALE
—BETWEEN DOUBLE
WIDE HOMES, 'GRADE
SURFACE TO SWALE
70'
SHUT OFF
ACCESS ROAD B
PLAN - DOUBLE WIDE LOT
SCALE 1 " = 20'
28'
PARKING 1 2020'
GRADE SURFACE
TOWARDS THE SWALE
O
Mm
�N-SITU SAND
SWALE CROSS SECTION
SCALE: 1/2"
NEW YORK STATE ITMENT OF HEALTH
IT-
0
"M n�,,:
•
•
NE BASE.
BE 8 OUTLET W SPEED LEVELER5
06C110 rt%L I iIMGT 01+VE MOUND TOPSOIL TO
ALLOW FOR SETTLEMENT
Date&
TOPSOIL
These glans for.1
w
WHITE
ANTI-S I � Ii 4IN Y dw FABRIC
are hereby AcceF B43 ELGIN MAT
ReViewed by: _e . I .
for th( I ugmmitsir, oner of Hoalt
IN-SITU-SAND—
ly 1 .9 2016
Ny<
RTMh'N*1'()I.HhA1 I'll
01,37A ICT 011,10.
LOTS ORIGINALLY
CALCULATE ADDr
FOR SINGLE WIDE HOMES,
AND SIZE SHALLI
1OFF FOR DOUBLE WIDE HOMES
RAIN I NTFNSITY.
ADDITIONAL ARE/
]OUR FOR 100 YEAR STORM
1960 SF
WIDE: 980 SF / UNIT X 2
TIME -.1 HR
RUNOFF: 2" X IS
STORAGE CAPACI
53 CF (100 YR STORM)
'TIME FOR FULL S I
_E IS 7 SF/FT X 55- = 385 CF.
FOR A 12- DEEP
RAIN AT, 5 MIN / IN IS 1 HOUR
4' PERFORATED PIPE-J
•"iN-SITU SAND
GROUNDWATER OR IMPERVIOUS LAYER
ELGIN DETAIL
SCALE: 1/2" - I'
to
C4 IT IS A VIOLATION OF THE LAW FOR ANY PERSON,
UNLESS ACTING UNDER THE DIRECTION OF THE
LICENSED ENGINEER, TO ALTER ANY ITEM OR
PORTION OF THIS DOCUMENT IN ANYWAY.
THE ENGINEER HAS NOT BEEN RETAINED TO
PERFORM OR PROVIDE INSPECTIONS OR
CERTIFICATIONS ASSOCIATED WITH THIS PROJECT.
-,ds
APPENDIX 75A SE* Wm
NCES: RvA "L 4_0Z.N .1.
TREATMENT AREA' N
TREATMENT AREA' Y LINE: 10.
AR 0
mm�;m
SEPTIC TANK TO W :1- 20' f
wx
ti
Nk-1
'OFF A M
a jab
IT IS THE RESPONSIBILITY OF THE
OWNER/CONTRACTOR TO ENSURE THAT ALL
MATERIAL ORDERED COMPLIES WITH PROJECT
REQUIREMENTS.
RYAN M. BURNS, WS P.E. LICENSE No. 084062
DESTROY PREVIOUSLY DATED DRAWINGS
1 1 12/14 1 RB I ENG. COMMENTS
�N=o.DAT TBY I REVISIONS
UPSTATE DESIGN ASSOCIATES
RESIDENTIAL DESIGN AND CIVIL ENGINEERING
RYAN M. BURNS, P.E. IRA S. ADLER, P.E.
180 PLEASANT STREET 10 MADELINE DRIVE
KEESEVILLE, NY 12944 SARATOGA SPRINGS
t P: 518-572=0256 515-573-2549 1"
518-536-9058 QUEENSBURY VILLAGE M
IN SEPTIC / RU
PROJECT- ELC NOFF DESI
LOCATION:• PETRIE LANE, QUENSBURY NY
DATE: 10Z10Z07 ..__
DRN. BY. RMB SHEET NO. —