SEP-0376-2023 0--w
SEPTIC DISPOSAL PERMIT Office Use Only
kPu IE Permit#: � b-bllo 2L6
'roam ofQueensbary
Permit Fee:$
JUN 2 7 2023 Invoice#:
742 Bay Road,Queensbury,NY 804
P:528-761-8256 www_vqueensb ry.n19wN OF QUEENSBURY Septic variant . No
QUI�DING & CODES
Flood Zone? o
Wetlands? O Reviewed By:
Project Location: 5-
0
Tax Map #• _ 2,
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 L4 4Y Installed? (choose one) ❑ [,�'
PARCEL INFORMATION:
Topography lat Rolling ❑ Steep Slope % Slope
Soil Nature and ❑ Loam ❑ Clay ❑ Other, explain:
Groundwater At what depth?
Bedrock/Impervious material At w at 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 115D gallons (min. size 1,000 gallons, add 250 gallons for each garbage cylinder or
spa/hottub L'X�S��►, '(4r, K
System Absorption field w/#2 stone Total length 1000 ft.; Each Trench ft.
Seepage Pit w/#3 stone How many: ; Size:
Alternative System Bed or other type: A rC -J L1
Holding Tank System Total required capacity? ; tank size ;
# of tanks
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): l e f (I�'�
Mailing Address, C/S/Z: Z log, , k6cre-m 1f
Cell Phone: .�i�6--1�6-04,�1 Land Line: �� 7f$-!I y
Email: e5b-',gfev G�►�SSPl1�c:fro...
® Primary Owner(s):
Name(s): 'Tel ra-e3 A'v7Ag ono r-c
Mailing Address, C/S/Z_: So %ri- Jf�- Dr;yr
Cell Phone: I-IS- 23 Land Line:
Email:
❑ Check if all work will be performed by property owner only
• Contractor:
Contact Name(s): FAX TA:Q l�e_,,
Contractor Trade: pl•.r~�j.'nc,
Mailing Address, C/S/Z: Z "wwl_ r'f
Cell Phone: f(!�- 7 Y6-0gf � Land Line: 5'!�- 7rrg-1/7 Y
Email: e14l,if A. � � b r r,(. .-�--
**%A1nrLrs" Comp Lcumentation .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: Ew'► fh.
Cell Phone:- 'lido- I -p _ Land Line:
Email:xOIL ln4 c� ► bSci ��` p,,�,..
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 a
requirements of the Town of Queensbury Sanitary Sewage Disposal Ordinance.
PRINT NAME: EAIC17
SIGNATURE: DATE:
(awTOWN OF Q UEENSB URY
742 Bay Road, Queensbury, NY. 12804-5902
Septic System Checklist
Q9— Plan to scale
fJO Received Deep hole perc test results from engineer/Architect if applicable(Town Approved Engineers and r
Architects;June 30 to April 15 Town Engineer for unapproved Engineers and Architects
AJ All wells on property and adjacent properties shown 1c� �
. �,iJh. c
eater line shown Muter c4aakor well 10' separation to any part of system
etback to property lines show 10'or more for any part of system
1!�eptic tank and pump stations 10'from foundation, 50'from any well/lake/wetland, 10'from any waterline
rtf//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
^� Seepage pit 150'from well 50'from septic tank
.4Seepage Pits 3-times diameter apart
Septic tank and pump stations over 30 gallons 50'from watercourse or wetland
I
?12Distance from bottom of trench or system 24"to bedrock or mottling 36"within 1000'of Lake George
P Leech field 100'from watercourse or wetland
t'*Toe of mound or bottom of retaining wall 10'from property line, 100'from well, 20'from foundation
Yi-! Provide Engineer/Architect stamp for bed or design systems
0 Department of Health Approval for all mobile home park new systems Flood Plain requirements
NG 2' above established flood elevation to bottom of system
All tanks anchored or 2'above flood elevation
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BUILDING DEPARTMENT
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with our comments shall not be;construed;as — —-V
i indicating the plans and sp u�ld n t� Codes of
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SHEET NO. OF
WATER • WASTEWATER • STORMWATER CALCULATED BY DATE
SOLUTIONS SCALE
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