2024-0192 SEPTIC DISPOSAL PERMIT Office Use Only '
= APPLICATION Permit#: 2-C1 "
Town of CZucensbury ��, .._-•---_•-...-
Permit Fee:$_
�: i r.\ll Invoice#: t
742 Bay Road,Queensbury,NY 12804 n II
P:518-761-8256 www.queensbury.net APRk 2 J f'�° � 1 Septic Varianca .,
I, r -
«}G' - . ., Flood Zone? NO
_ Wetlands? No Reviewed By:
Project Locations 21 Facy 5+
Tax Map #: 13 -1•-3 i
RESIDENCE INFORMATION: _ _ __
Year Built Gallons #of bedrooms: X gallons per =total daily flow
per day bedroom Garbage Grinder Yes No
1980 or older 150 3 lio 330 Installed? (choose one) ❑
1981-1991 130 Spa or Hot Tub Yes No
1992-Present 110 Installed? (choose one) ❑
PARCEL INFORMATION:
Topography (Flat Rolling [' Steep Slope % Slope
Soil Nature ✓Sand ❑ Loam ❑ Clay ❑ Other, explain:
Groundwater At what depth? A//A
Bedrock/Impervious material At what depth? N/4
Domestic Water Supply ❑ Municipal E Well ❑Lake
(if well or lake, water supply from any septic system absorption is
ft.)
Percolation Test Rate: per minute per inch (test to be completed by a
licensed engineer/architect)
PROPOSED SYSTEM INFORMATION:
Tank size /00o gallons (min. size 1,000 gallons, add 250 gallons for each garbage cylinder or
spa/hot tub Y We AeQ. Vj ng The ei:51Zri Se,4 c Tc.K '1f
System Absorption field w/#2 stone Total length !co ft.; Each Trench 3 ft.
Seepage Pit w/#3 stone How many: ; Size:
Alternative System Bed or other type:
Holding Tank System Total required capacity? ; tank size
# of tanks
Septic Application' Revised July 2022
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): EAZL 5&;ig-ey (TOO
Mailing Address, C/S/Z: '2. Gdwer Wtireen St 499Y
Cell Phone: Sq:c 7 y(,-ogs6 Land Line: Citb- 79e3-�/9y
Email: esl„)p/fy2 ' bCCI a.C.CoN--
• Primary Owner(s):
Name(s): Vicki Cox
Mailing Address, C/S/Z: 22&tf Q.'
Cell Phone: q'r4-%1 - I Zto Land Line:
Email:
❑ Check if all work will be performed by property owner only
• Contractor:
Contact Name(s):__315S� �c.__ _..® ; _
Contractor Trade: PLUM 6`•7 f ' 7/�/C'
Mailing Address, C/S/Z: 2 4, er £ 4ic e.. f
Cell Phone: S5-746 85`6 Land Line: 7' - 7c -$/t�/
Email: esli: /eye 1 ) c,AC
**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: EAtc 54:p fFY
Cell Phone: S S- 'n yfc-o46s% Land Line: 14—-fic- 'Q
Email: ,e tt:pieyo�;Werii ' .Co&...
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 'sl,:p to y
SIGNATURE: �JJ �. DATE: 41242y
Septic Application Revised July 2022
,
Oro1h QUEENSBURY
OF
742 Bay Road, Queensbury, NY. 12804-5902
Septic System Checklist
CtePlan to scale
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)
Lio All wells on property and adjacent properties shown •
efi.i3Water line shown Municipal or well 10'separation to any part of system
�6 Setback to property lines show 10'or more for any part of system
�
c/tISeptic tank and pump stations 10'from foundation, 50'from any well/lake/wetland, 10'from any waterline
(J 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)
9teJ Septic tank sized for number of bedrooms and add 250 gals for Jacuzzi tubs/garbage grinder each
',1°,Q Leech Field 20'from foundation 100'from any well 10'from water line
1•/ll Seepage pit 150'from well 50'from septic tank
aSeepage Pits 3-times diameter apart
7f/f Septic tank and pump stations over 30 gallons 50'from watercourse or wetland
Distance from bottom of trench or system 24"to bedrock or mottling 36"within 1000'of Lake George
':Leech field 100'from watercourse or wetland
iJ,,Toe of mound or bottom of retaining wall 10'from property line, 100'from well,20'from foundation
NiA Provide Engineer/Architect stamp for bed or design systems
k
rfsib'Department of Health Approval for-all mobile home park new systems Flood Plain requirements
f 2'above established flood elevation to bottom of system
All tanks anchored or 2'above flood elevation
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295.13-1-33 2024-0192 i T • ; 1 _.;
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Cox, Vicky Li r
I ! ! ! 60, _ ____ __1 !
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. ; . 22 Easy Street 1j1
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Residential Septic Alteration _.,
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