SEP-0796-2023 SEPTIC DISPOSAL PERMIT Office Use Only
APPLICATION_ . . Permit#: S _07 lo'Zo7��
Town of CIncenstnny ECIEDVE
- CV
Permit Fee:$
742 Bay Road,Queensbury,NY 12804
DEC 1 9 2023 ; invoice#:
P:518-761-8256 www.queensbury.net Septic Varianc; NO
TOWN OF QUEENSBURY
BUILDING:2, CODES I Flood Zone? NO
Wetlands? No Reviewed By: AA
Project Location: 2. L �l
J r 5 1 -0,,As
Tax Map#: — I
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) ❑ rje
1981-1991 130 l3o CZO Spa or Hot Tub Yes No
1992-Present 110 Installed? (choose one) ❑
PARCEL INFORMATION:
Topography Flat Rolling ❑ Steep Slope % Slope
Soil Nature 0 Sand ❑ Loam ❑ Clay ❑ Other, explain:
Groundwater At what depth?
Bedrock/Impervious material At what depth?
Domestic Water Supply [g 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 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 LLC ft.; Each Trench SSA. 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): 610c�w`s C ✓ S e P1'_
Mailing Address, CA/Z: S-41 13 „C „ /c 4
Cell Phone: CO)157-ci®ci? Land Line:
Email: lral✓P rvwrwt*,/SeQlvL , i�
• Primri Owner(s):
Name(s): y ' -1vv,er✓1
Mailing Address, C/S/Z: 7 1,,t t,,5s ,ii s C,'}
Cell Phone: (cL \Zbo-. 'l3 N Land Line:
Email: .
❑ Check if all work will be performed by property owner only
• Contractor:
Contact Name(s): . c,-,,,1 s " -SCcot'`t
Contractor Trade:
Mailing Address, C/S/Z: S&niG -. e_. Q
Cell Phone: CS14156-1-quen Land Line:
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: ZA., IP....,1a...er'
Cell Phone: (5114) 57--9 j7 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: . L., at' 1,
SIGNATURE: DATE: 6 /eitz_3
Septic Application Revised July 2022
Aft
F TOWN QUEENSBURY
� � OF
742 Bay.Road, Queensbury, NY. 12804-5902
Septic System Checklist
ilDPlan to scale
Y n 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)
5 i Silt
.NC) All wells on property and adjacent prope s show
e f of 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
��
tc 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
, j1&.Seepage pit 150'from well 50'from septic tank
IVA Seepage Pits 3-times diameter apart
'11 Septic tank and pump stations over 30 gallons 50'from watercourse or wetland
Distance from bottom of trench or system 24"to be rock or mottlin 36"within 1000'of Lake George
bedrock 0.
trzeech field 100'from watercourse or wetland
Toe of mound or bottom of retaining wall 10'from property line, 100'from well,20'from foundation
idA Provide Engineer/Architect stamp for bed or design systems
x
WO Department of Health Approval forall mobile home park new systems Flood Plain requirements
14) 2'above established flood elevation to bottom of system
!✓1) All tanks anchored or 2'above flood elev„ation
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• Ryan Lemery
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