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SEP-0647-2023 (4(7) SEPTIC DISPOSAL PERMIT Office Use Only APPLICATION Permit#: o( L -- 2 2 Town of Qucens6ury Permit Fee: $ 8� Invoice#: (Q 2-L 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.queensbury.net Septic VarianceNOi Flood Zone? No ` C Wetlands? No Reviewed By: Project Location: 25 Ploo1:345 I'y.e Tax Map #: 315. 6 - 7- - Z 1 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 Fsand ❑ Loam ❑ Clay ❑ ain: DECEOW/ Ein Groundwater At what depth? .6 Bedrock/Impervious material At what depth? 0 11 OCT 1 1 2023 Domestic Water Supply Well ❑Lake TOWN OF QUE NSBU Y (if well or lake, water supply from any se tlittlifErtree :.LQe®.;, ion s 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 System Absorption field w/#2 stone Total length ft.; Each Trench ft. Seepage Pit w/#3 stone How many: ; Size: Alternative System Bed or other type: #lrc- 24 N I+raforc 11,,,05 DTo F.-- 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): i&c Sepltc t Mailing Address, C/S/Z: 2 /pWPr te,z)y rr. Sf Cell Phone: st 5 ? 4(p-ocrc 6 Land Line: 51-t-;79$-ir/Q y Email: ,SIi;pip/u7 675-ef .C.Cc:,._. • Primary Owner(s): Name(s): foid,c Mailing Address, C/S/Z: 'ZS Floc k``"y 6•rj Aire Cell Phone: cii3-1Cq t 2.131 Land Line: Email: Check if all work will be performed by property owner only • Contractor: Contact Name(s): T15 Septi.ct_®e `,,,. Contractor Trade: 9 -" y-s 1 Sip f�c Mailing Address, C/S/Z: Z /oi..e►- 14,Aere,- 1 t Cell Phone: C/A- 9 -or4.f6, Land Line: 'f'r$- 791-8/T Email: es1,,iglpy ;hSSpolC.lbY.-- **Workers' Comp documentation 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: Eric , Sh tp fey Cell Phone: 174-- (l 6-0z5 6 Land Line: 5)46-?1$-$lc 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: t iC f Iv le SIGNATURE: ` / DATE: Ic//G 113 Septic Application Revised July 2022 -Ir iliatTOWN OF QUEENSBURY 742 Bay Road, Queensbury, NY. 12804-5902 Septic System Checklist 0 Plan to scale 1✓a Received Deep hole perc test results from engineer/Architect if applicable(Town Approved Engineers and Architects;June 30 to April 15 Town Engineer for unapproved Engineers and Architects) 0 All wells on property and adjacent properties shown ' - kr.--87/-ppi AMMO Rizi OVA , v/tJWater line shown Municipal or well 10'separation to any part of system (1"</ etback to property lines show 10'or more for any part of system -1/-Septic tank and pump stations 10'from foundation,50'from any well/lake/wetland, 10'from any waterline pi/Po 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) (I . CGS Septic tank sized for number of bedrooms and add 250 gals for Jacuzzi tubs/garbage grinder each q-khl eech Field 20'from foundation 100'from any well 10'from water line 4Seepage pit 150'from well 50'from septic tank IJ//Seepage Pits 3-times diameter apart 6if Septic tank and pump stations over 30 gallons 50'from watercourse or wetland G° Distance from bottom of trench or system 24"to bedrock or mottling 36"within 1000'of Lake George .-l✓Leech field 100'from watercourse or wetland Toe of mound or bottom of retaining wall 10'from property line, 100'from well,20'from foundation WO Provide Engineer/Architect stamp for bed or design systems lb Department of Health Approval for all mobile home park new systems Flood Plain requirements 0 2'above established flood elevation to bottom of system kg All tanks anchored or 2'above flood elevation I ` j l I + i 1 I I I 1 1 + ! i ! i i I ; I I , I i � I i ' I I i I I I ) ,OWN OF C1uEE.NS3URY—' I ( 0 if- . 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