SEP-0435-2023 SEPTIC DISPOSAL PERMIT Office Use Only
APPLICATION Permit#: `P—fl� — 202'5
Town of Qucensbury -- ��
rc
o Permit Fee:$
Invoice#: ''‘
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net JUL 9 7 2023 J Septic Varianc-; NO
t
TOWN OF QUEENSBURY Flood Zone?P
BUILDING & CODES Wetlands? 4\� Reviewed By:6111"0
Project Location: t 2 Q v en, LTa.e
Tax Map #: 3oI• S'— l - 3 �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) ❑ F
1981-1991 130 Spa or Hot Tub Yes No
1992-Present 110 1111 0 Installed? (choose one) ❑
PARCEL INFORMATION:
Topography at Rolling ❑ Steep Slope % Slope
Soil Nature [-Sa'nd ❑ Loam ❑ Clay ❑ Other, explain:
Groundwater At what depth?
Bedrock/Impervious material At what depth? 0'
Domestic Water Supply F7Municipal ❑ 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 125o 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: 1Sa ft' 2;,•('/tr,74,1-
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): ZBS See( t nrg;
Mailing Address, C/S/Z: 2 /•..r W4t e S I Q4I"1tr
Cell Phone: Fick l tar085 b Land Line: S$- 79g i°/q y
Email: f 5&y/tY 0 i i•sSPpiL(.(Co 6...
• Primary Owner(s):
Name(s): I?4I74rd E. 04v.e) ur,
Mailing Address, C/S/Z: i2 +pvao„S /glee Qd'y
Cell Phone: Land Line:
Email:
❑ Check if all work will be performed by property owner only
• Contractor:
Contact Name(s): E As c 54,1"4y 6*5 cel a'c i 17,4:r,)
Contractor Trade: hl�r•.ifi .,
Mailing Address, C/S/Z: Z (. ., t ' ,# 'Ff ni &P}
Cell Phone: CV-- 7 y6-o c$ Land Line: S.S- 7P -7/Q y
Email:
**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: talc 7 !h i//i-ey
Cell Phone: 'co%-7 (16-083-4 Land Line: S% '79I SC/9 Y
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: E OQ 1C 3- 5I•'p/,
Y
SIGNATURE: DATE: 7/1/7,3
Septic Application Revised July 2022
141.-so TOWN Oi' QUEENSBURY
•� 742 Bay Road, Queensbury,NY. 12804-5902
Septic System Checklist
Plan to scale
r 4 Received Deep hole perc test results from engineer/Architect if applicable(Town Approved Engineers and
�ArL_AlI
chitects;June 30 to April 15 Town Engineer for unapproved Engineers and Architects)
wells on property and adjacent properties shown /'A
iNater line shown Municipal or well 10'separation to any part of system •
TLetback to property lines show 10'or more for any part of system
jSeptic tank and pump stations 10'from foundation 50'from any well/lake/wetland 10'from any waterline
E9: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)
kii.-4 .
Septic tank sized for number of bedrooms and add 250 gals for Jacuzzi tubs/garbage grinder each
11'l Leech Field 20'from foundation 100'from any well 10.from water line
.OrSeepage pit 150'from well 50'from septic tank
PlkSeepage Pits 3-times diameter apart
116. Septic tank and pump stations over 30 gallons 50'from watercourse or wetland
fJ distance from bottom of trench or system 24"to bedrock or mottling 36"within 1000'of Lake George
�g
'/Leech field 100'from watercourse or wetland
!"I Toe of mound or bottom of retaining wall 10'from property line 100'from well 20'from
Foundation
Aib Provide Engineer/Architect stamp for bed or design systems
/44 Department of Health Approval for all mobile home park new systems Flood Plain requirements
" 0 2'above established flood elevation to bottom of system
All tanks anchored or 2'above flood el
evation
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f i ; 301.5-1-34 SEP-0435-2023 u
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