2024-0495 ti
Office Use Only
SEPTIC DISPOSAL APPLICATION
0 Permit#: - 04-c
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Permit Fee:$
Town ofQuccnsbury
742 Bay Road,Queensbury,NY 12804 Invoice#:
P:518-761-8256 www.queensburv.net
Flood Zone? Y TYPE: ; N
Project Location: 2 1 L4e r v'.c k C. rc if Wetlands? Y
` Y .. Reviewed By: w \ g
Tax Map #: 30 /.
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 F u I V _ DO Installed?
1981-1992 130 ' C�n1
1992-Present 110
SPij2024
PARCEL INFORMATION AWN OF QUEENSBURY
TOPOGRAPHY cg i ' n Stee Slope % Slope
SOIL NATURE Sand Loam Clay Other, explain:
GROUNDWATER At what depth: of
BEDROCK/IMPERVIOUS MATERIAL At what depth: r?
DOMESTIC WATER SUPPLY IT/Municipal I^ Well I 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 iS•o gallons (min. size 1,000 gallons, add 250 gallons for each garbage
cylinder or spa/hot tub oNly y,.ifin;“? 0 wew TAy/K
SYSTEM Absorption field w/#2 stone Total length ft. Each trench 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): rips Sppf:t pry:,,
Mailing Address, C/S/Z: 2 1-owtr ivaeir•-, 9 t QV; w Y
Cell Phone: Tip'7 I( o' 6 Land Line: SA- 791- ¶ 19 9
Email: BPSCp/oy Coa-•,•
• Primary Owner(s):
Name(s): K',44:VIq TAYr~b42y
Mailing Address, C/S/Z: 24 He ii+r;c!< C rc
Cell Phone: 631- 36S• 99Iy Land Line:
Email: KP;4.I.: 4 . Ift/m4n �9w��,'/• C.►w•
❑Check if all work will be performed by property owner only
• Contractor:
Contact Name(s): Fe•c, S'4 ley
Contractor Trade: Sep.'c f Pl,».h•w'
Mailing Address, C/S/Z: 2 Lever W trnrr If 4,0 k, Y
Cell Phone: ' g % -n6-o45 , Land Line: ciq,•7gc ct199
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:
Cell Phone: _ Land Line:
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: ECG G ?1ti piney
SIGNATURE: q,� dt.
DATE: 9/I012.V
Septic Alteration Application Revised May 2024
_4_ TOWN OF QUEENSBURY
��
742 Bay Road, Queensbury, NY. 12804-5902
Septic System Checklist
S`l0 Plan toscale —rank, rteMaGc.Yrwn h
1JJ&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)
NI 0 All wells on property and adjacent properties shown
6 Water line shown Municipal or well 10'separation to any part of system 'WPM G ii)G. uv&
1'('JSetback to property lines show 10'or more for any part of system
stS Septic tank and pump stations 10'from foundation, 50'from any well/lake/wetland, 10'from any waterline
W & 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)
4 i Septic tank sized for number of bedrooms and add 250 gals for Jacuzzi tubs/garbage grinder each
1
b/1A Leech Field 20'from foundation 100'from any well 10'from water line
IV/A Seepage pit 150'from well 50'from septic tank
4Seepage Pits 3-times diameter apart
j1.45 Septic tank and pump stations over 30 gallons 50'from watercourse or wetland
N,4 Distance from bottom of trench or system 24"to bedrock or mottling 36"within 1000'of Lake George
A/ (0. Leech field 100'from watercourse or wetland
1./-!d Toe 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
&0 Department of Health Approval for all mobile home park new systems Flood Plain requirements
tJ' 2' above established flood elevation to bottom of system
tkh' All tanks anchored or 2' above flood elevation
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- —SEP-11-2021
TOWN OF cUE;N 1 301.12-2-54 2024-0495 '
BUILQIN3& poOEs_ Trombley, Kristina 1 _
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