2024-0267 •
Office Use Only
SEPTIC DISPOSAL I if'
t E Permit#: <21.°a4" ��?
85,0✓
Town ofQuc n ry MAY 31 2024Permit Fee:$/fin,I
742 Bay Road,Queensbury,NY 12804 - Invoice#: �Lo`t r b���
P:518-761-8256 www.queensbury.net TOWN OF C�UEENSBURY
BUILDING&CODES Flood Zone? Y TYPE: ;&\1
Project Location: 31 2e n'S flr:ve wetlands? Y
Reviewed By: T2
Tax Map #: 301. 12- 3®1Y
STRUCTURE INFORMATION Garbage Grinder Yes No
Year Built Gallons #of X gallons per =total daily flow Installed? ❑ ❑
Per day Bedrooms Bedroom
1980 or 150 Spa or Hot Tub
older El ElInstalled?
1981-1992 130 3 3 90
1992-Present 110
PARCEL INFORMATION
TOPOGRAPHY Flat Rollin n Steeo Slope___ % Slope
SOIL NATURE Sand Loam I Clay Other, explain:
GROUNDWATER At what depth: 6
BEDROCK/IMPERVIOUS MATERIAL At what depth: >'
DOMESTIC WATER SUPPLY FNAlunicipal P Well n Lake (if well or lake, water
supply from any septic system absorption is feet)
PERCOLATION TEST Rate: per minute per inch (test to be completed
by a licensed engineer/architect)
PROPOSED SYSTEM INFORMATION
TANK SIZE `000 gallons (min. size 1,000 gallons add 250 gallons for each garbage
cylinder or spa/hot tub Ned, 'rahK (PIjs'c')
SYSTEM Absorption field w/#2 stone Total length !SO ft. Each trench 5O ft.
Seepage pit w/#3 stone How many: ; Size:
Alternate system Bed or other type:
Holding tank system Total required capacity: ; tank size:
; # of tanks:
Septic Alteration Application Revised May 2024
CONTACT INFORMATI ON: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): 1135 Sepik. DA:0
Mailing Address, C/S/Z: 2 Lower Warier, 1'1*
Cell Phone: --]g 6-0$'-(p Land Line: 7Q15—V 9 y
Email: e54:fieYc� i 6T.*? .Cow•
• Primary Owner(s):
Name(s): Pe-f e & 11
Mailing Address, C/S/Z: 3 4 2e Pics Pr.
Cell Phone: 55tql. `1 qc,- Lo 3 6 Land Line:
Email:
❑Check if all work will be performed by property owner only
• Contractor: fr
Contact Name(s): T r3S 5E p#s( D ,'"
Contractor Trade: Plvie4 b."9 t 5et b.c
Mailing Address, C/S/Z: 2 Lower Wgv,'ewe 5t
Cell Phone: P'S-746'O 465'6 Land Line: 'S':%- WI— ce
Email:
**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: ERK• 3 54 10
Cell Phone: '�'4-'7 4(o-0$rj"6 Land Line: 5�+ 7q�e(gy
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: ERhc. 7 511, 214),
SIGNATURE: ere. J( . .94S, DATE: 512421
Septic Alteration Application Revised May 2024
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0,1*- TOWN Cf QUEENSBURY t,g.
742 Bay Road, Queensbury,NY. 12804-5902
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Septic System Checklist
k. Plan to scale .
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" Received Deep hole pert test results from engineer/Architect if applicable(Town •
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Architects;June 30 to April 15 Town Engineer for unapproved Engineers and Architects)Approved Engineers and
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" A• ll wells on property and adjacent properties shown •
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Water line shown Municipal or well 10'separation to any part of system • •
. 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 waterline
• ►" ' 'Septic tank to foundation crawl space/slab on grade,grade in crawl top ace must be above
P of septic tank
for 0',Separation required(field verification required) •
• Septic tank sized for number of bedrooms and add 250 gals for Jacuzzi tubs/garbage grinder each •
L• eech Field 20'from foundation 100'from any well 10'.from water line
tjepage pit 150'from-well 50'from septic tank •
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/"'I Seepage Pits 3-times diameter apart
Septic tank and pump stations over 30 gallons 50'from watercou •
Watercourse or wetland
d• istance from bottom of trench or system 24"to bedrock or mottling 36"within 1000'of Lake George •
If L• eech field 100' from watercourse or wetland
�Noe of mound or bottom of retaining wall.10'from property line 100'from well 20'from •
Foundation
Provide'Engineer/Architect stamp for bed or design systems . .
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I"}�l Department of Health Approval for all mobile home park new systems Flood Plain requirements
2'above established flood elevation to bottom of system •
rf All tanks anchored or 2'above flood elevation
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