2024-0291 ' Office Use Only
tJ. SEPTIC DISPOS CO-PlielkT •
Permit#: 2'6 _ Z9
3 2524
Permit Fee:$ 65
Town of Qucrnsbury
TOlNN OFIL� QUE� E+aSBUS�Y
742 Bay Road,Queensbury,NY 12804 E3Uit� <`3�GOi� _._, Invoice#: ��►7
P:518-761-8256 www.queensbury.net N
Flood Zone? Y E: • N
J
Project Location: 23 c Ie r fNlgr Dt.ue Wetlands? Y /�
Tax Map #: Zqd . '-I-
STRUCTURE INFORMATION Garbage inder 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 ❑ vk
Installed?
1981-1992 130 52 o
1992-Present 110
PARCEL INFORMATION
TOPOGRAPHY at Rollin n Stee Slope % Slope
SOIL NATURE ,wand Loam I Clay Other, explain:
GROUNDWATER At what depth: if
BEDROCK/IMPERVIOUS MATERIAL At what depth:
DOMESTIC WATER SUPPLY T— Municipal ell Lake (if well or lake, water
supply from any septic system absorption is loo+ feet)
PERCOLATION TEST Rate: per minute per inch (test to be completed
by a licensed engineer/architect)
PROPOSED SYSTEM INFORMATION
TANK SIZE 1` 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 /So ft. Each trench So 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
A
CONTACT INFORMATI ON: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): T65 Se'1k flrq�M
Mailing Address, C/S/Z: 2 Lows✓ 14,46er• St Q6 S;44 /Zgo y
Cell Phone: SA- 7 /6-°SS6 Land Line: 5 191-%/9
Email: . 511; Sky a ;45.01AC•(o'--
• Primary Owner(s):
Name(s): /`(nd pt.. Sw•.CIP
Mailing Address, C/S/Z: t3 6`e., 1114 De:ve Q$Y, A- k' /2a® S'
Cell Phone: 5 i%- 260- 43%1 Land Line:
Email:
❑Check if all work will be performed by property owner only
• Contractor:
Contact Name(s): X61 Seee< 0.4 „
Contractor Trade: 1,14,n,b.:1 Set lic
Mailing Address, C/S/Z: 2 Lowy,' k/Q+,re, Sf Qin; n-f' /?go r..
Cell Phone: S%-746-o$S6 Land Line: Sit• ?l'-149 (/
Email: PS 4.-lo/a y a7 r Wyk_ . Co.,...
**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: Ertzc 3". 5.4 1ey
Cell Phone: 51%-�Ye-0s Land Line: 'fit• 7? - T/9 5f
Email: to54.i/er'Pi 6sSPpCr . 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: `Ric J. '4:ploy
SIGNATURE: "!/,' /J' fre, DATE: 6//z/'z q
Septic Alteration Application Revised May 2024
AIWA
lEs
TOWN OF QUEENSBURY
742 Bay Road, Queensbury, NY. 12804-5902
Septic System Checklist
U° Plan to scale
t-C) 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)
Gtr` e„ , ¢o s t b
ti)All wells on property and adjacent properties shown v
et-e--later line shown Municipal or well 10'separation to any part of system
el-i ,eetback to property lines show 10'or more for any part of system
r .(eptic tank and pump stations 10'from foundation, 50'from any well/lake/wetland, 10'from any waterline
A/ii 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)
/ISeptic tank sized for number of bedrooms and add 250 gals for Jacuzzi tubs/garbage grinder each
-e ?Leech Field 20'from foundation 100'from any well 10'from water line
y
t•.!!.
Seepage pit 150'from well 50'from septic tank
/ 4 Seepage Pits 3-times diameter apart
j--f1 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
q(7Leech field 100'from watercourse or wetland
r440 Toe of mound or bottom of retaining wall 10'from property line, 100'from well, 20'from foundation
10 Provide Engineer/Architect stamp for bed or design systems
1J0 Department of Health Approval for all mobile home park new systems Flood Plain requirements
2' above established flood elevation to bottom of system
All tanks anchored or 2' above flood elevation
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