SEP-0792-2023 SEPTIC DISPOSAL PERMIT Office Use Only
) APPLICATION Permit#: JG, — O2 \2- Z02,3
Town ofQvicensbvry EC
ermit Fee:$ 65
LEOV
invoice#: 6B:),?:)
742 Bay Road,Queensbury,NY 12804 DEC , � �� � I Septic Variance? Y
P:518-761-8256 www.queensbury.net i 1)
TOWN OF OUEENSBURY Flood Zone? Y
BUILDING & CODES c j Wetlands? Y Reviewed By:(
Project Location: /g(1 rhir / e-,"
Tax Map #: it2iif ^ / �g Z—
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) D M-
1981-1991 130 Spa or Hot Tub Yes No
1992-Present 110 / )® - (3 � Installed? (choose one) ❑ Fi
PARCEL INFORMATION:
Topography ix Flat Rolling ❑ Steep Slope % Slope
Soil Nature `i Sand ❑ Loam ❑ Clay ❑ Other, explain:
Groundwater At what depth? A4.4f;
Bedrock/Impervious material At what depth? A/ab
Domestic Water Supply Er Municipal ❑ Well ELake
(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 LOP/ gallons (min. size 1,000 gallons, add 250 gallons for each garbage cylinder or
spa/hot tub
System Absorption field w 1 Total length& ft.; Each Trench .5 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
z
4
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s):
Mailing Address, C/S/Z: X d,j e, ,5,t�c3G,4 ,,."628d
Cell Phone: 3'-2 --t7O7 Land Line: 32g- r'�h/d 9g
Email: dePo�r&4 i;,7ef./,,.�.l0 fcd, cokr,
• Primar O n s
Name(s): 4, ,
Mailing Address, C/S/Z: 3 . &,,ae:ns'.,ly, /2er '
CeH P orre~ Land Line: Se. ..79,7'77I
Email: • i' a e,90)••,-,
❑ Check if all work will be performed by property owner only
• Contractor:
Contact Name(s): cs�o e, _Lr, -4 ",;w6
Contractor.Trade: a ,✓ ,- -.
Mailing Address, C/S/Z: o e,.sd., ' 'G7y -J' '
Cell Phone �°- 27Z•-Z 7o7 Land Line:,)-;-°Y )t z%'
Email: ✓S. /yes, Go y
**Workers omp documentation must be submitted with this application**
• Engine r(s):
Name(s): i4 - -/ ' •
Mailing Address, C/S/Z:2'c ,y,L4 W/ v SG-, /28L6
Cell Phone: U'/- €7 6.4)9,5 Land Line:
Email: ['vim ri.7&/' ? i7 "5,Y„e5,e.,1-y, �y , 'S
Contact Person for Compliance in regards to this project: �`'A. °-'�"�'�-
Cell Phope: 0,e, Z,7�-e 707 Land Line: jiA.- 5' Jd V''
Email:,1'cecid(el. " 0 „n,4.__0).4-74sro5, c —
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.
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A
PRINT NAME: �/�.,. / ie-d, C_,
SIGNATURE: �� DATE:%--/z.'79
Septic Application Revised July 2022
•
41111106.,4,26.
•
r31� TOWN Y YIY OF r�v
Q UEENSB 1,IRY
742 Bay Road •
, •Queettsbury,NY. 12804-5902 • •
Septic System Checklist •
Plan to scale •
.
./aL' Received Deep hole pert test results from engineer/Architect If applicable(Town Approved Engineers d •
Architects;June 30 to April 15 p Town Engineer for unapproved Engineers and Architects)
g an
AV All wells on property and adjacent properties shown . •
tWater line shown Municipal or well 10'separation to anypart of system • •
Y
yE .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 wateriine
• Ni 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)
•
eptic tank sized for number of bedrooms and add 250 gals for Jacuzzi tubs/garbage grinder each •
yLeech Field 20'from foundation 100'from any well 10'from water line •—iA+
Seepage pit 150'from well 50'from septic tank
•
•
Seepage Pits 3-times diameter apart •
Septic tank and pump stations over 30 gallons 50'from watercourse or wetland •
1/6
distance from bottom of trench or syst !24" bedrock or mottling36"within 1000' .
�"' of Lake George
Leech field 100'from watercourse or wetland
•
Toe of mound or bottom of retaining wal1.10'from property line 100'from well 20'from
Foundation
•
/0
Provide Engineer/Architect stamp for bed or design systems • .
•
epartment of Health Approval for mobile home park new sy_st ms Flood Plain requirements y nts
• PO 2'above established flood elevation to bottom of system
WAIT tanks anchored or 2'above flood elevation
' 1
•
•
NI
NEW YORK Department
STATE OF
OPPORTUNITY. of Health
KATHY HOCHUL JAMES V. McDONALD, M.D., M.P.H. JOHANNE E. MORNE,M.S.
Governor Commissioner Acting Executive Deputy Commissioner
October 24, 2023 .
Ryan K. Riper, P.E. h 11023_
RK Engineering, PLLC �
225 Ruggles Rd -
Saratoga Springs, NY 12866 i'c' V! OF OUEENSBURY
5;i1C.!)iNG 8,CODES
RE: Forest Park Mobile Home Court, Facility 56-6822
Replacement Onsite Wastewater Treatment Systems at Lots 8 and 10 Timber Lane
Queensbury(T), Warren County
Mr. Riper:
We have this day, approved the plans and specifications for the above-referenced project.
Application for this project was duly made by you on plans titled, "RHP Properties (Forest
Park)," and was most recently received by this office October 10, 2023. The project includes
installation of replacement onsite wastewater treatment systems to serve Lots 8 and 10 Timber
Lane. The systems consist of one 1,000-gallon septic tank and two 55' laterals with ADS Hancor
ARC 24 chambers, to serve one 3-bedroom home each. Approval of these plans is conditioned
on the following:
1. That the proposed works be constructed in complete conformity with the approved
plans or amendments thereto;
2. That all components of the proposed works be installed, operated, and maintained as
per the manufacturer's specifications;
3. That approval be granted by other agencies or municipalities have jurisdiction;
4. That the design professional inspects the construction and provides certification to this
office that construction was completed in accordance with the approved plans.
Certification shall also be provided to the Town Office Building and Code Enforcement.
The responsibility for the design of the sanitary system lies solely with the design professional
and the proper operation of the sanitary system lies solely with the owner. The purpose of the
Department of Health review is for compliance with the New York State Sanitary Code and in no
way guarantees proper system operation. A set of approved plans is being retained in our files.
Sincerely,
d44.kaa►f. Dieemdr.
Brendan O'Connell
Engineer Trainee
NYSDOH-Glens Falls District Office
77 Mohican St.
Glens Falls, NY 12801
(518) 793-3893
Glens Falls District Office,77 Mohican Street,Glens Falls,NY 12801,518-793-38931gfdo@health.ny.gov
PLOT DATE:
PROJECT #:
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