2024-0292 Office Use Only
rr� SEPTIC DISPOSAi ► d1 ' E
Permit#: 24)24 O 2-92.
JUN 1 3 Permit Fee:$ `8w
Town ofQucensbury //k�
742 Bay Road,Queensbury,NY 12804 ,,, � Invoice#:
TOWN OF QLi =1 ;�i.�r3ur I
P:518-761-8256 www.queensbury.net BUILDING Si cop
._. r T-.. Flood Zone? Y TYPE: ;
Project Location: lq Oct K - Pee C:Pc le Wetlands? Y (�
Reviewed By: AAIc
Tax Map #: 3 0 2 . 1 i - 2 . 3 Y
STRUCTURE INFORMATION Garbage Grinder Yes No
Year Built Gallons #of X gallons per =total daily flow Installed? El
Per day Bedrooms Bedroom
1980 or 150 Spa or Hot Tub
older Installed? El
1981-1992 130 39 0
1992-Present 110
PARCEL INFORMATION
TOPOGRAPHY Flat Rollin n Steen Slope_, % Slope
SOIL NATURE ,/Sand Loam J Clay Other, explain:
GROUNDWATER At what depth: e
BEDROCK/IMPERVIOUS MATERIAL At what t depth: ('
DOMESTIC WATER SUPPLY /lunicipal I- 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 lee o gallons (min. size 1,000 gallons, add 250 gallons for each garbage
cylinder or spa/hot tub Cv.441"9 leoo 64140-4414
SYSTEM Absorption field w/#2 stone Total length too ft. Each trench SD 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): CBS Sepgc �t4r
Mailing Address, C/S/Z: 2 Lower WA rrers 5 t Q$Y, , r /2-$® y
Cell Phone: 5'i 1_716_ O$SC Land Line: Sicte 7 S Sig Sr
Email: 25A:ple7-a� i bscep/ic .Ca w.
• Primary Owner(s):
Name(s): Marc t /J, iy WI kg
Mailing Address, C/S/Z: I 1 Oak Ted,p C s is le 08 t rti fr" /Z10_ y
Cell Phone: PS- 5 % - 4O'I Land Line:
Email: yf5O4 Ja9",q• /. Co a
❑Check if all work will be performed by property owner only
• Contractor:
Contact Name(s): T6i Sep / C Drag✓+
Contractor Trade: plt...b.; t cei1 J4 C
Mailing Address, C/S/Z: 2 1.04•0i Warr..,. If Qgf o n. /Z10 4'
Cell Phone: Sid- 71*6-Og5-, Land Line: 'Pee,- 7g 1-4/9 Sr
Email: •e51. ./Iey ,bs S-pre.r• 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: eRIC 3• Sti; ley
Cell Phone: Sim 1q6-01b5-6 Land Line: Sid- fe
Email: .e i1.p!e y a 1,b Sceled ir. (e
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: ER'C J• 5h.n / y
SIGNATURE: - /aid", DATE: 6/ll/21.1
Septic Alteration Application Revised May 2024
IOW
t. tw.. TOWN OF QUEENSBURY
742 Bay Road, Queensbury, NY. 12804-5902
Septic System Checklist
if° Plan to scale
0/4- 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)
o k, 't 6e,-/),
>� All wells on property and adjacent properties shown— rNA,u h i 4 j v
rWater line shown Municipal or well 10'separation to any part of system
(iv etback to property lines show 10'or more for any part of system
-cSSeptic tank and pump stations 10'from foundation, 50'from any well/lake/wetland, 10'from any waterline
pi 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)
(IZ f
l Septic tank sized for number of bedrooms and add 250 gals for Jacuzzi tubs/garbage grinder each
V.,e,Leech Field 20'from foundation 100'from any well 10'from water line
Seepage pit 150'from well 50'from septic tank
) . Seepage Pits 3-times diameter apart
(4.11Septic tank and pump stations over 30 gallons 50'from watercourse or wetland
t-'1;-e-,) Distance from bottom of trench or system 24"to bedrock or mottling 36"within 1000'of Lake George
1' -"Leech field 100'from watercourse or wetland
tiLA Toe of mound or bottom of retaining wall 10'from property line, 100'from well, 20'from foundation
IJO Provide Engineer/Architect stamp for bed or design systems
l Department of Health Approval for all mobile home park new systems Flood Plain requirements
Al0
2' above established flood elevation to bottom of system
All tanks anchored or 2' above flood elevation
(,I- te4J
P e o ► e ( f ; L I r1- ( ' , . P r 6 i '.P r L ,- ri E-
Mew -
- - - -- — - io Ft — -,----; ;- '- - -- - ;- - - -- --- ----.-- — -- P—
-— ,- 1 - - ;� - -- - -- — ---- --- — -- —�--
- #�� n —-- � ` A — -- i i - —, --- -— -- 0
—� — �; QUEE�Sg�T I I
- !► <,, M e
_; — f�1Nr,DEPAR a1�on;�omPtlea as —ITO W N O F Q U E E N S B U RY - - - -
- el ' - --, B r Hilted e a 1 not_be con ns are-•In
��'' asedm°U enfs sh �lficatio P of 'BU;ILDING-& CODES DEPT. - y----
-- ,� wi�o�ur eom,QmplanS ande'gguild;ng �0d s I I S —=
;radio ce `141t ' I ; ;Reviewed By•
;;a�
_ i — - ',— - -{L�1;- _ !'Date; —;- tS - —!— —i L'-
I Mate.,- -----r— -�—
li
, I —� j—� — — , — —. —E-� L-c- S4,I:.c�— boo 0 6e -IG,—IT., ,— I — —' —I
—•-___J i I 0 ft1 _ Iv
_ I— I y 1
J
—I rn Lo roi, po-rck _ i I
a yi O„ t t x 51, a_-- l000 (_ih_Tj 4ii_kII I --
P
i
r = v
_
N F LCCCFY , r
-� ( '
fD I1 oa K Tp C,'rc l 0y IQ ✓9 5 _ 50 Ff. 0 •
- -
I -a 1 1 !
D 1r—! I I ! ' I I r 1
-- - -- fflurcz t f9+i y i Y✓i ell — —I i --�— iFFoot. -- —I -
- kb I— -r — —I -- — — — — — — — — —' 1—
I ��nasN9EInO'-JJo NMQI
I 12 0 1: litOZ t I ',Mt
I fl I 1— v
1 C -- � -- — I --,...— - — - --
—
; I — -i 1 1