SEP-0248-2022 /-' SEPTIC DISPOSAL PERMIT Office Use Only
APPLICATION Permit#:
Town of Quccns6ury --Permit Fee:$ D S- 00
742 Bay Road,Queensbury,NY 12804
r[FMI
CY 0 5 2 02 2 I II voice#:
P:518-761-8256 www.aueensbury.net ( eptic Variance?jRev1ew
lood Zone? Y
TOWN OF 60EENSRUIRW Wetlands? Y y•
6UILDINO' &CODES i
Project Location: /
Tax Map #: Ag7• (11- I— l�
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 Installed? (choose one) ❑
PARCEL INFORMATION:
Topography ❑ Flat Rolling ❑ Steep Slope % Slope
Soil Nature Osand ❑ Loam ❑ Clay ❑ Other, explain:
Groundwater At what depth? 7
Bedrock/Impervious material At what depth?
Domestic Water Supply ❑ Municipal EffWell ❑Lake
(if well or lake, water supply from any septic system absorption is
ft.)
Percolation Test Rate: �Pt minute per inch (test to be completed by a
licensed engineer/architect)
PROPOSED SYSTEM INFORMATION:
Tank size /,2 6'0 gallons (min. size 1,000 gallons, add 250 gallons for each garbage cylinder or
spa/hot tub
System Absorption field w/#2 stone Total Iength,,,�ft.; Each Trench
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 April 2021
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): i el;4 /�"
Mailing Addres , C/S/Z: - �2� /�2, . �J 9,9 7
Cell Phone: Land Line:
Email: "/ii14ern W/ CJ //GSSd�'J`�/dl�{'• eveyJ
• Primary Owner(s):
Name(s): -T"e 4-f .4$odr
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): yo C -�-e
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: -?Ci C- 1_7 ,?C, Land Line:
Email:
**Workers' Comp documentation must be submitted with this application**
• Engineer(s):
Name(s): �,i'//,/.�/r°P,�2/.t/G 7��L/GA �, ^ 1%P y ' `�y /f�'
Mailing Address, C/S/Z: �' �PLrJ/�l/� J72eeT) ���yr i �) y
Cell Phone: .6-1dr— �/a/—�/� l/S Land Line:
Email: z 4Se yA-g.3 6) %i 00, 401t1
Contact Person for Compliance in regards to this project:
Cell Phone: Land Line:
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: YY
SIGNATURE: DATE:
Septic Application Revised April 2021
TOWN OF QUEENSBURY
742 Bay Road, Queensbuny, NY. 12804-5902
Septic System Checklist
Plan to scale
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)
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
Septic 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
Nk Seepage pit 150'from well 50'from septic tank
Seepage Pits 3-times diameter apart
1 Septic tank and pump stations over 30 gallons 50'from watercourse or wetland
distance from bottom of trench or syst 24" edrock or mottling 36"within 1000' of Lake George
Leech field 100'from watercourse or wetland
V)4N'Toe 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
ON Department of Health Approval for all mobile home park new systems Flood Plain requirements
*-2' above established flood elevation to bottom of system
t&AII tanks anchored or 2' above flood elevation
Revised 4/15/2021
O
�z
GLEN LAKE ROAD LINE 200-R �\\ \ O 0
LINE 150-ft FROM WELL- 7- N
FROM WELL ��\\ 00
112 n frn11 d
6' � \, QZ NZI
LINE 10-ft \ U N W
\ OFFPL LINL 10-ft M 3
OFF� N�
o \
0
LINE 10 -ft \
FROM W L� "__�--- FIEL / \
_ 108
i/ \ \\ / \
102 \
\
\\ 06 \
LINE 50 \ \ \
FROM WEL _- `\ \ \ 04 1
100 \
/ \ 1-1/2"PVC \
\ \ PRESSURE LINE 02
198
\ \k / LINE 1 WEI
\FULL M ON \ / / / �� FROM WEL2�
\GRILL W LL \
98 5'x 8'- l 100 \\
l I / PU�f TANK \ � I
100 / / l \\ NEIGHBOR'S \ / \/
ELL \ WELL 4/ LINE 100-fr
15'-6" // ! rM WELL
" I I
5k 9'
—T— — l ! EXIST
SEPTIC TANK HOUSE
\ � / LINE 50-ft
\ \ /LINE 50-ft] FROM WF/LL /
• \ 2q�,� \\ //
p \ FROM WELL
100
-Record Dm in V\PG RECORD DRAWING w
11 Nacy Road
SCALE.1"=30' Town of Queensbury
for
Guy DiMemmo
6/19/23,8:59 AM Mail-Guy DiMemmo-Outlook
Fw: Record Drawings - 11 N
Guy DiMemmo <gdimemmo@vcssoftware.com>
Tue 6/13/2023 1:54 PM
To:reece3689@yahoo.com <reece3689@yahoo.com>
Ql 1 attachments (586 KB)
6-12-23 Septic Record Documants- 11 Nacy.pdf,
Reece,
From the Septic engineer
.Guy J. DiMemmo I CEO
Founder and Chief Executive Officer
Visual Computer Solutions, Inc.
Office: 732-730-9009 Ext 204
E-Mail: gdimemmo@vcssoftware.com
Book a call with me here!
From: George Yasenchak<georgeyas3@yahoo.com>
Sent:Tuesday,June 13, 2023 1:39 PM
To:Guy DiMemmo<gdimemmo@vcssoftware.com>
Subject: Record Drawings- 11 N
Good afternoon Guy - I have to apologize- there was a mixup between my daughter and me.
I was under the impression that you had not paid for the design-however, today my daughter went thru
our books and informed me that indeed you had paid for the design and only had to pay us for the
inspections
and record items.
Again - I apologize for the confusion.
Attached is a letter of certification along with photos and the Record Drawing that the Town of
Queensbury
needs to give you your C of O.
Tonya will be sending you -via email- a bill for$375 for the inspections and record items.
Have a great day
https://outlook.office.com/mail/id/AAQkAGEyMjclZjlwLTk3N2MtNGZiMSlhYTY2LWNiYWJkZjEzODgzOAAQAKT17tohSZJKmGtl3%2Belkbg%3D 1/2
6/19/23,8:59 AM Mail-Guy DiMemmo-Outlook
Sincerely,
George Y
https://outlook.office.Gom/mail/id/AAQkAGEyMjclZjlwLTk3N2MtNGZiMSlhYTY2LWNiYWJkZjEzODgzOAAQAKT17tohSZJKmGtl3%2Belkbg%3D 212
Engineering America Company
8 Fielding Street
Glens Falls, NY 12801
518-615-0201
Georeeyas3@vahoo.com
June 12, 2023
Re: Record Drawing&Certification
DiMemmo House
11 Nacy Road
Town of Queensbury, NY
Building Inspector
Dear Sir:
This letter is to certify that the septic system was installed in substantial compliance with the drawings
provided for this system{Project 22-0106 by EACo on 5-4-221 as follows:
- I am the designer of this septic system.
- I am personally familiar with the site conditions and in of those conditions the system
was designed in compliance with the Town of Queensbury standards requiring two(2)feet of
separation between the bottom of the trench and the annual high-water table in the area.
- I observed the system being installed on June 3rd, 2022.
- To the best of my knowledge the system was installed in substantial compliance with the design
documents, and to the best of my knowledge no field conditions were encountered which deviated
from the conditions observed at the time the system was designed.
- Attached is a stamped Record Drawing of the system, and photographs of the system during
installation.
If you have any questions regarding these items please contact me.
Sincerely,
George Yasenchak, PE
.`.:
Cc: DiMemmo
ry
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Photos of Septic System
11 Nacy Road
June 3,2022.
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