SEP-0648-2023 SEPTIC DISPOSAL PERMIT Office Use Only
APPLICATION Permit#: — e't-o - 2e2S
Town of Quccnsbuq•
D IE C E O V E e rmit Fee:$ ---
n voice#: q
742 Bay Road,Queensbury,NY 12804 OCT 1 1 2023
P:518-761-8256 www.queensbury.net 4 Septic Variance
TOWN OF QUEENSBURY Fl3od Zone? No
BUILDING&CODES
--Wetlands? No Reviewed By:
Project Location: 1 2 1 (cl. vj�1iw")DECE1:1VE15
Tax Map#: b , ta`" I + UI
OCT 11 2023
RESIDENCE INFORMATION: TOWN OF QUEENSBURY
Year Built Gallons #of bedrooms: X gallons per =total daily flow BUILDING&CODES
per day bedroom Gar page Gr inder Yes N
1980 or older 150 Installed? (choose one) 111
[`
1981-1991 130 Spa or Hot Tub Yes No
1992-Present 110 //O 3 3p Installed? (choose one) ❑
PARCEL INFORMATION:
Topography (flat Rolling ❑ Steep Slope % Slope
Soil Nature Sand ❑ Loam ❑ Clay ❑ Other, explain:
Groundwater At what depth? t
Bedrock/Impervious material At what depth? .r
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 /az2 gallons (min. size 1,000 gallons, add 250 gallons for each garbage cylinder or
spa/hot tub
System Absorption field w/#2 stone Total length l ft.; Each Trench 6OO 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): Mvc,.:v ck-e- -
Mailing Address, C/S/Z:
Cell Phone: ( s l'6g57--cltic? Land Line:
Email: iovGcv,Ufhvy,,ss .sep c ,
• Primary Owner(s):
Name(s): Alite rcode
Mailing Address, C/S/Z: t
Cell Phone: CctIA V?Y—?h`( Land Line:
Email:
El Check if all work will be performed by property owner only
• Contractor: AJ
Contact Name(s): Mor^i'` 59 c' ei0/-c
Contractor Trade:
Mailing Addr s, C/S/Z: S�'( t/r-'tc _,4 L
Cell Phone: (sMT'57-'irM Land Line:
Email:
**Workers' Comp documentation must be submitted with this application**
• En ineer s
Name(s): S
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email:
Contact Person for Compliance in regards to this project: Li
Cell Phone: (c)S" ,u23 J 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: 2cA., 2/2,�=%mod'
SIGNATURE: DATE:
Septic Application Revised July 2022
vroi TOWN GF QUEENSBURY
742 Bay Road, Queensbury,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)
g
All wells on property and adjacent properties shown
14Water 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
VSeptic tank and pump stations 10'from foundation 50'from any well/lake/wetland 10'from anywaterline
. *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
�
Ij Leech Field 20'from foundation 100'from any well 10.from water line
Seepage pit 150'from well 50'from septic tank •
/OA 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 system 24"to bedrock or mottling 36"within 1000'of Lake George •
Igf Leech field 100'from watercourse or wetland
itt rk Toe of mound or bottom of retaining wall 10'from property line 100'from well 20'from
�n
Foundation
AM
-Provide Engineer/Architect stamp for bed or design systems •
MA'Department of Health Approval for all mobile home park new systems Flood Plain requirements
•
2'above established flood elevation to bottom of system
��All tanks anchored or 2'above flood elevation
f y'� d$�ao�� GAD ,
LOT
330258 ' ,; F` �f.
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TOWN ON DQ _NSBURYRTMENT ® �p
BUILDING DA ARTMENT } 1 11„. '�
Based on our limited examination,complianc.; ®Q ) A R
with our commentsali not be const i Pe, • '- li
indicating the plan Ind specific t tons are ins
full compliance w
Banc. h the Buildin0 Codes of f
New York Staie. o� w
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' TOWN OF QUE .NSBU -Y
BUILDING & CODES D ''T.
• Reviewed By: '00 Ali
316.13-1-24
SEP-0648-2023 ',
• Turcotte, Allen &Janine
12 Bardin Dr
. \
Residential Septic Alteration •
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