SEP-0784-2023 SEPTIC DISPOSAL PERMIT Office Use Only
APPLICATION Permit#:
Town ofQucensbury gECEnV e}�—
Permit Fee:$
Invoice#:
742 Bay Road,Queensbury,NY 12804 DEC 1 1 202
P:518-761-8256 www.queensbury.net Septic Varianc: No
TOWN OF QUEEI`,!SEURY Flood Zone? No
BUILDING' 8: CODP'', S
Wetlands? No Reviewed By:
Project Location: 1 Ad 7 51<Pp, iZ
Tax Map #: 3° 1 . 1y- 1 -51
_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 3 3qo Spa or Hot Tub Yes No
1992-Present 110 Installed? (choose one) ❑
PARCEL INFORMATION:
Topography NXIat Rolling ❑ Steep Slope % Slope
Soil Nature land ❑ Loam ❑ Clay ❑ Other, explain:
Groundwater At what depth? f'
Bedrock/Impervious material At what depth? o
Domestic Water Supply 11'IVlunicipal ❑ 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 WO 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 Zoo ft.; Each Trench So 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): ray Cepi-:c -F IDra4•
Mailing Address, C/S/Z: Z tows k/.rr'r. 5 t
Cell Phone: S13-196-oZf Land Line: rk 7f$-$l9cl
Email: e5k,Aley a ;bsSepf.c
• Primary Owner(s):
Name(s): S-Eeve••+ Sb9t,1t#c k
Mailing Address, C/S/Z: L.1 1.ady 5li pp r Di
Cell Phone: Land Line: SI 1-743-13o q
Email:
Check if all work will be performed by property owner only
• Contractor:
Contact Name(s): re5 Sep t n,-g:ti
Contractor Trade: Pio*/h•ay f ,SPQ 1•c
Mailing Address, C/S/Z: Z A '- Lva✓/0'h 5t
Cell Phone: 14-7%-0$r,'6 Land Line: 5�S' N$--$/99
Email: 054p(e y ;b'fP,Lc.a .—
**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:
Cell Phone: 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: EAtC. T 54: fey
SIGNATURE: q glyforDATE: LZ/$1Z3
Septic Application Revised July 2022
MIA
F-4,-,0
TOWN. OF QUEENSBURY
742 Bay Road, Queensbury, NY. 12804-5902
Septic System Checklist
610 Plan to scale
olt 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)
GLcseA. k.N o,A1,,, i-o have, s-0,,r, S'a1 (S
nJ 6 All wells on property and adjacent properties shown C/
yWater line shown Municipal or well 10'separation to any part of system
4e-5-Setback to property lines show 10'or more for any part of system
"/`f/JSeptic tank and pump stations 10'from foundation, 50'from any well/lake/wetland, 10'from any waterline
tv/A 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)
V-ed"Septic tank sized for number of bedrooms and add 250 gals for Jacuzzi tubs/garbage grinder each
`Gf Leech Field 20'from foundation 100'from any well 10'from water line
' Seepage pit 150'from well 50'from septic tank
t''0 Seepage Pits 3-times diameter apart
(/-t-1 Septic tank and pump stations over 30 gallons 50'from watercourse or wetland
V Distance from bottom of trench or system 24"to bedrock or mottling 36"within 1000'of Lake George
(� 5 a.)7, co G i /..s
L Leech field 100'from watercourse or wetland
r.ri/,4 Toe of mound or bottom of retaining wall 10'from property line, 100'from well,20'from foundation
0 O Provide Engineer/Architect stamp for bed or design systems
i✓c) Department of Health Approval foiall mobile home park new systems Flood Plain requirements
r'`3 2'above established flood elevation to bottom of system
NA All tanks anchored or 2'above flood elevation
nd1- i~ a. Ft a1 -za►--cam
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