SEP-0014-2024 f
SEPTIC DISPOSAL PERMIT Office Use Only
APPLICATION___ __ ___._._._—I Permit#: — o01�-20?
Town ofQruct bnn f�1 �� Li `i
L ` �.�� fl
Permit Fee:$ I��_.
JAN 0 4 2024 Invoice#: lob lQ,2
742 Bay Road,Queensbury,NY 12804 �J
P:518-761-8256 www.queensbury.net Septic Varia e? NO
TOWN OF (=CEE D1.1RY
BOIL DiING cc CODES Flood Zone? No
Wetlands? No Reviewed By: M5
Project Location: 2.o TO g;dy.e Rip
Tax Map#: Z 3 . - I -1ct
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) I �
PARCEL INFORMATION:
Topography 14lat Rolling Steep Slope %Slope
Soil Nature RSand Loam ❑ Clay ❑ Other, explain:
Groundwater At what depth? qo
Bedrock/Impervious material At what depth?
Domestic Water Supply ❑ Municipal [ I- ell ❑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 j000 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 16o ft.; Each Trench 11 o 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): z8S Sri t Prc„-.
Mailing Address, C/S/Z: 2 Lower Warr-e,, ff
Cell Phone: Sicb-7y4-e,$S'6o Land Line: 'Sri- 7g7-S/9y
Email: est,p/r �, hccep
• Primary Owner(s):
Name(s): g e„ 1s 4 e
Mailing Address, C/S/Z: 2o' o 1N7e. RO
Cell Phone: 51$ - 6qS- bogs Land Line: 5-13- 74y-g6SS
Email:
❑ Check if all work will be performed by property owner only
• Contractor:
Contact Name(s): E$s $'epl c f P►,,'n
Contractor Trade: Sep.,c + Qli.„,ti,:..5
Mailing Address, C/S/Z: 2 Lo.v - Wcrrr, St
Cell Phone: S'db-7 4G-ogT6 Land Line: Si If- 7fg-$/9
Email: e56.p1ey i hsf��� �•(o,�
**Workers' Comp documentation must be submitted with this application**
• Engineer(s):
Name(s): WotleS t11i►1fer.4.1
Mailing Address, C/S/Z: 6e4 5.
9►r4 f°9
Cell Phone: SA- 5%1- Oo7A Land Line:
Email:
Contact Person for Compliance in regards to this project: FR.c. J. 54,/2/e y
Cell Phone: St 43- 196-0(65'G Land Line: Sim 79eg- es/9y
Email: f'54;94 t7 i bs.Spri•r•ro,..-.
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: �R �C T. 54,Pley
SIGNATURE: •= Q7 DATE: 1/3/2 y
Septic Application Revised July 2022
��' " TOWN OF QUEENSBURY
742 Bay Road, Queensbury, NY. 12804-5902
Septic System Checklist
JO Plan to scale
y'C 3 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)
116.CAll wells on property and adjacent properties shown
el-CS-Water line shown Municipal or well 10'separation to any part of system
-1&Setback to property lines show 10'or more for any part of system
(CP Septic tank and pump stations 10'from foundation, 50'from any well/lake/wetland, 10'from any waterline
n/1it 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)
ya Septic tank sized for number of bedrooms and add 250 gals for Jacuzzi tubs/garbage grinder each
lef Leech Field 20'from foundation 100'from any well 10'from water line
dA Seepage pit 150'from well 50'from septic tank
NIA Seepage Pits 3-times diameter apart
6/6-geptic tank and pump stations over 30 gallons 50'from watercourse or wetland
qts Distance from bottom of trench or system,'to bedrock or mottling 36"within 1000'of Lake George
'ti:ejLeech field 100'from watercourse or wetland
/►CfToe of mound or bottom of retaining wall 10'from property line, 100'from well,20'from foundation
(C J'Provide Engineer/Architect stamp
JJ
NA Department of Health Approval foi all mobile home park new systems Flood Plain requirements
i,/ii.2'above established flood elevation to bottom of system
All tanks anchored or 2'above flood elevation
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WARNING-It Is a Holetiw of the New York Stale Educaton Low Section 7209.2 for eny person.unless acting under the direction of a Prohesionel Engineer m exempt Land Surveyor to alter ihle de enl In any way. If dtered,the altering Professional shall comply with the mqufremenle of the New York Stote Education Low Section 7209.2
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Dunhams Bay Fish & Game Club o"�'°*ST Nuumba ftvhlmDiap*M °a""
Q 2080 Ridge Road
m z Town of Queensbury,Warren County NY
°, �D Sao _
O5.'
O
.fT REPLACEMENT
ON-SITE SEWAGE DISPOSAL SYSTEM
91MM SITE PLAN-DETAILS-NOTES
a -
Timothy W. Wales, P.E.
•
CONSULTING ENGINEER
68 Waterview Drive
Saratoga Springs,New York 12866
Tel: (518) 704-2480
January 17,2024
Dunham Bay Fish& Game Club _____________-_ _ _ ____._____--
P.O.Box 4265 �;. `ice ',
Queensbury,NY 12804 I . \� �+ y
Ret Sewage Disposal System-Engineer's Certification 11 FEB 0 1 In f Lai
.20 0 Ridge Road, T/O Queensbury ?
ZDci TOWN C..
Dear Members ".'_ f-u------ -: -- _' ,_ _
The construction of a replacement sewage disposal system for the Member Clubhouse at the above referenced
location, Tax #253.-1-7-9 has been completed. The installation was completed by IBS Septic & Drain Service on
1.16.29 1°1
As the engineer of record,I certify to the Town of Queensbury as follows:
1. I am in fact the designer of the system.
2. I am personally familiar with the actual site conditions and in consideration of those conditions the system
was designed in compliance with the Town of Queensbury standards requiring two feet of separation
between the bottom of the absorption trench and the annual high-water table and Part 75A of the New York
State Department of Health Sanitary Code.
3. Wales Engineering staff,under my direct supervision,inspected the system at the time of construction and I
have personal knowledge that it was constructed in compliance with the design. Noted field variation that
were encountered during construction which deviated from the conditions observed at the time the system.
was designed.
*Existing waterline from well was located where New tank was being installed.New tank location was
adjusted to avoid conflict with the waterline. Contractor notified Engineer of the observation and was
directed to move the tank away from the waterline, min 10'.
4. Wales Engineering prepared an asbuilt plan(see attached)depicting the septic system as it was constructed,
including the appropriate measurements. Septic tank to bldg., well to closest point of bldg., distribution to
bldg.and disposal field to bldg.Inspection was performed on January 15,2024.
If you have any questions or require additional information,please contact me at your convenience.
Sincerely,
g44.p,SH`tW. rs9�✓�7'
r:w S BUILT.
'Timothy W.Wales,PE ,r °
Lisc.#077263 `*
0772�3 0i'
�'OFESSTnaT'y
4
1\ �, FEB 01 202,
1 ;' 1\iNC= __ 1.:i _;RY
Gtloi Septic Tank
co
1 1 CO
m
1 r— Clubhoue® = Pistol
A lawn 1 . Range
I c
-, I A.. - - --- - -iB i
1 �,, // / lb 0 —z El a 0 0 0 0
/
7i'qy \�_,/ // r+ s_ / 20.74d- Acres
_lc__-N i/ 253.-1-79
1 \ 1\ E . /. Distribution Box
I / ..2p
1 \\ lawn '
1 E�dsBng
® 1 11 ` Well
' 1
'1 Sewage Disposal Field
1 - 4 laterals 0 40'
1 1 — 120'separation to well— xx' to building RECORDED AS—BUILT DIMENSIONS
1 \\ STRUCTURE 1ENSION__
\ A—C 35'
i
\\ parking S A—D 53'
1 \ as
\ A—E 71'
I \
\\ 'j A—DBOX 60'
1 \1 B—C 83'
I 1
I1 B—D 93'
1
\
1 B—E 66'
_
i �\ B—DBOX 50'
1 \
\ \
\ E—WELL 122'
Note:
THE AS—BUILT DIMENSIONS SHOWN WERE TAPE MEASURED DURING CONSTRUCTION WITH ACCURACY
SUITABLE FOR OWNER'S USE. THESE ARE NOT SURVEYED DIMENSIONS,
Dunhams Bay Fish & Game Club
2080 Ridge Road
Town of Queensbury, Warren County NY
ON-SITE SEWAGE DISPOSAL SYSTEM
AS BUILT I AS-BUILT