2024-0239 i
Office Use Only
p SEPTIC DISPOSA '' 11--' r!' 1/( ' E
Permit#: Z Z-2\' ' 62 :11
- MAY 16 2024 Permit Fees85 _
Town ofQucensbury
3
742 Bay Road,Queensbury,NY 12804 TOWN OF Invoice# i:!
QUEENSBURY Whv
P:518-761-8256 www.queensbu v.net BUILDING&CODES Flood Zone? Y TYPE: ;
Project Location: It Pleg5q•i t Line Wetlands? Y /N>
Reviewed By: &k S
Tax Map #: 301. Il - 3 - 11
STRUCTURE INFORMATION Garbage Grinder Yes No
Year Built Gallons #of X gallons per =total daily flow 1 Installed? El vt-
Per day Bedrooms Bedroom
1980 or 150 Spa or Hot Tub
older Installed?
1981-1992 130 3 3q0
1992-Present 110
PARCEL INFORMATION
---------- -- --- ----- -
TOPOGRAPHY Flat Rolling Stee Slope__ l% Slope
SOIL NATURE Sand L Loam I Clay Other, explain: •
GROUNDWATER At what depth:
BEDROCK/IMPERVIOUS MATERIAL At what depth: 9
DOMESTIC WATER SUPPLY Municipal Well F Lake (if well or lake, water
supply from any septic system absorption is feet)
PERCOLATION TEST Rate: per minute per inch (test to be completed
by a licensed engineer/architect)
PROPOSED SYSTEM INFORMATION
TANK SIZE /Deo gallons (min. size 1,000 gallons, add 250 gallons for each garbage
cylinder or spa/hot tub VC,‘sj EY;5 t;Mq +aw(<
SYSTEM _ Absorption field w/#2 stone Total length 2o0 ft. Each trench S 0 ft.
Seepage pit w/#3 stone How many: ; Size:
Alternate system Bed or other type:
Holding tank system Total required capacity: ; tank size:
# of tanks:
Septic Alteration Application Revised May 2024
CONTACT INFORMATI ON: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): xeS SePf:c '� ®r4�s•
Mailing Address, C/S/Z: 2 lever W ri , 51 Q 6 }'
Cell Phone: Stet-'7no" O' 5 , Land Line: 'St$- 744C' $/94
Email: e sit:�ley' a b55-PP1;c . Co..
• Primary Owner(s): nn
Name(s): /14,14 ,4 y 14v 10$
•
Mailing Address, C/S/Z: 17. Pec5a..# e Q$ r
Cell Phone: 'S t ct- 23 2 - MSc Land Line:
Email: aft+horlf fe.los 6o sgr ct:/, Co.+.
❑Check if all work will be performed by property owner only
• Contractor:
Contact Name(s): : 95 Sep f:c ? Qr4..,
Contractor Trade: Sep l.c ' PL1 b.
Mailing Address, C/S/Z: 2. Cower G/'f re oft Si Q, Y
Cell Phone: feet"7y6-0isf 6 _Land Line: St1.-79e& V9 S'
Email: e51,/piey 2 i bSSPJ7��l• Co w•
**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 any questions regarding this project: ER i c 3• Sli.1p/e y
Cell Phone: S4cg- 7 q (,-o%5.6 Land Line: 'S"t 7411-S/9
Email: ect7:?/ey 'd.'bSSp l c .Co.o.•-
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: CI ;C 5 A:o/e),
r
SIGNATURE: 'l/_ . ,'• e DATE: 5142.�
Septic Alteration Application Revised May 2024
TOWN OF QUEENSBURY
Nip- 1 742 Bay Road, Queensbury, NY. 12804-5902
Septic System Checklist
Plan to scale
14) 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) Wed_ k& As h cv
Scot Epi b-
l•) All wells on property and adjacent properties shown MUYN'kc.0 fZJ (A4,44.,,,--
.Q�S Water line shown Municipal or well 10'separation to any part of system(.(
: �SSetback to property lines show 10'or more for any part of system
( -(/SSeptic tank and pump stations 10'from foundation, 50'from any well/lake/wetland, 10'from any waterline
OA 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)
6114 Septic tank sized for number of bedrooms and add 250 gals for Jacuzzi tubs/garbage grinder each
r',-e$Leech Field 20'from foundation 100'from any well 10'from water line
I-4Seepage pit 150'from well 50'from septic tank
h/ A.Seepage Pits 3-times diameter apart
Septic tank and pump stations over 30 gallons 50'from watercourse or wetland
1he/.S Distance from bottom of trench or system 24"to bedrock or mottling 36"within 1000' of Lake George
745eech
field 100'from watercourse or wetland
t1A. Toe of mound or bottom of retaining wall 10'from property line, 100'from well, 20'from foundation
t�-1s. Provide Engineer/Architect stamp for bed or design systems
Nip Department of Health Approval for all mobile home park new systems Flood Plain requirements
Ivy) 2' above established flood elevation to bottom of system
tell All tanks anchored or 2' above flood elevation
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