2024-0526 1--
Office Use Only
SEPTIC DISPOSAL APPLICATION Permit#: 2024'U 32-k0
Permit Fee:$
Town of Queensbury
742 Bay Road,Queensbury,NY 12804 Invoice#:
P:518-761-8256 www.queensburv.net Flo d Zone? TYPE: N
Project Location: `�4, Sc fq- .te 0 e lands? Y N
OCT 02 2024
e ewed By: Mi
Tax Map #: 295 a Id -- I- 49 TOWN OF QUEENSBUF;Y
BUILDING&CODES
STRUCTURE INFORMATION Garbage Grinder Yes No
Year Built Gallons #of X gallons per =total daily flow Installed? ❑ vt
Per day Bedrooms Bedroom
1980 or 150 Spa or Hot Tub
older Installed? I- 1
1981-1992 130
1992-Present 110 5 5 5 0
PARCEL INFORMATION
TOPOGRAPHY Flat Rollin n Steen Slope % Slope
SOIL NATURE V'Sand Loam I^ Clay Other, explain:
GROUNDWATER At what depth: e'
BEDROCK/IMPERVIOUS MATERIAL At what depth: ff.
DOMESTIC WATER SUPPLY 1/Municipal I^ Well I 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 150o gallons (min. size 1,000 gallons, add 250 gallons for each garbage
cylinder or spa/hot tub ex i1-lg 72,hk
SYSTEM Absorption field w/#2 stone Total length 250 ft. Each trench 50 ft.
Seepage pit w/#3 stone How many: ; Size:
Alternate system Bed or other type:
Holding tank system Total required capacity: ; tank size:
; # oftanks:
Septic Alteration Application Revised May 2024
CONTACT INFORMATI ON: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): 165 lep-14 j Dot ri
Mailing Address, C/S/Z: 2 Lowe.- Weir rep, i f Qg
Cell Phone: 5i --7Y6-os5'6 Land Line: SA;79 %/7' V
Email: e5l„ppy G71 bSSPpi.0 C�
• PrimaryffOwner(s)
Name(s): S4epA hl p Tee k Y1Y"i Oval\ 1 Y sf Zb 71-k
Mailing Address, C/S/Z: 1(1) 5eirri - 1E'ri Pa (2)�
Cell Phone: Sig,-33'S- 616-7 Land Line:
Email: 5, 616'5 Z o i3 CD ;1. Ca cr
n Check if all work will be performed by property owner only
• Contractor:
Contact Name(s): Er; plyY T85 /c ,1) �✓�
Contractor Trade: Sep ticj Ph•frs71,1, /ter 645
Mailing Address, C/S/Z: 1. Lower Weircefra S, Qr5 '
Cell Phone: ci -74 -o 5`6 Land Line: Sal-7fq-dll
i
Email: e5j
:��Py 'c� idSSPI��['•<� �-
**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,c. J j 4 fer
Cell Phone: TiS 746-013Th Land Line: 11'6'-79 V/Q7
Email: es11:p/Nye r 65519/.G.. Coy,,,
I,
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 ns• 54:p/e3y
SIGNATURE: qr„. ver:A7 DATE: !Ol2./7 y
Septic Alteration Application Revised May 2024
\ .
:Q. 1 Septic System Checklist
Town of Qucensbury
742 Bay Road
Queensbury, NY 12804-5902
lJ U Plan to scale
o/4 Received Deep hole perc test results from engineer/Architect if applicable (Town Approved Engineers
nd Architects;June 30 to April 15 Town Engineer for unapproved Engineers and Architects)
T
tJ/iAll wells on property and adjacent properties shown NCI C I NI vVQ4"er
t4tf Water line shown Municipal or well 10' separation to any part of system
9€'SSetback to property lines show 10' or more for any part of system
C e5 Septic tank and pump stations 10' from foundation, 50'from any well/lake/wetland, 10'from any
waterline
tf/ASeptic 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)
TO Septic tank sized for number of bedrooms and add 250 gals for Jacuzzi tubs/garbage grinder each
14-5 Leech Field 20'from foundation 100' from any well 10' from water line
r41Seepage pit 150'from well 50'from septic tank
piASeepage Pits 3-times diameter apart
Ci_/s Septic tank and pump stations over 30 gallons 50' from watercourse or wetland
tips Distance from bottom of trench or system 24" to bedrock or mottling 36" within 1000' of Lake George
/e/S Leech field 100' from watercourse or wetland
rIA Toe of mound or bottom of retaining wall 10' from property line, 100' from well, 20' from foundation
_ I_'' Provide Engineer/Architect stamp for bed or design systems
rA) Department of Health Approval for all mobile home park new systems Flood Plain requirements
Po 2' above established flood elevation to bottom of system
__ All tanks anchored or 2' above flood elevation
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Based on our limited examinatiocoMpliance ' , '... ,
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Thvith our cornments shall not be ponstrued as ;
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