2024-0580 1 ._ j
Office Use Only
SEPTIC DISP•. L PPL C 1 . 14 Permit#: 2-024_
2024 Permit Fee:$ ETD
Town of Qucen—bury
TOWN OF QUEENSBURY Invoice#
742 Bay Road,Queensbury,NY 12804 BUILDING& CODES
P:518-761-8256 www.queensbury.net
Flood Zone? Y TYPE: ; N
Project Location: tr3G iry 6lemf R4 Wetlands? Y
Tax Map #: 3oo. -
Y Reviewed By: 00
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 - Installed? ��
1981-1992 130
1992-Present 110 3 3 3
PARCEL INFORMATION
TOPOGRAPHY at Rollin n Steen Slope % Slope
SOIL NATURE ✓Sand I Loam Clay Other, explain:
GROUNDWATER At what depth: 9
BEDROCK/IMPERVIOUS MATERIAL At what depth:41
DOMESTIC WATER SUPPLY Municipal ✓Well Lake (if well or lake, water
supply from any septic system absorption is Ioo'"feet)
PERCOLATION TEST Rate: per minute per inch (test to be completed
by a licensed engineer/architect)
•
PROPOSED SYSTEM INFORMATION
TANK SIZE 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 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:
1„,,441(:k1 R.5er pn .IP t C'#/e4- ciA/Ie
Rep kce O- 3o t Lime to 0- et)
Septic Alteration Application Revised May 2024
CONTACT INFORMATI ON: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): T$5 567?sC % Prc.•.�
Mailing Address, C/S/Z: 2 Lowe.- tvcrre,-- 5 f 4$)'
Cell Phone: y(0-0%5 6 Land Line: Si d' 7N • S/9 y
Email: S �:��p +�hsropI 'c (c �•-•
• Primary Owner(s):
Name(s): 3'P Af Ye•�f
Mailing Address, C/S/Z: 2.5'3 C ei•.. b►-cok / '
Cell Phone: 4414 y` 5/3 ' 6051 Land Line:
Email: Jpr.'. ye`"9 t5 c'4ao• (a-
❑Check if all work will be performed by property owner only
• Contractor:
Contact Name(s): Er' c J. C�• .�pr
Contractor Trade: ph... b.;5 t lea .
Mailing Address, C/S/Z: 2
w 5 t CP e r $4-• �'
La �r !�r✓per.
Cell Phone: 5./46- - y6-v `11. Land Line: Cs V 7f i .c /9 S/
Email: t 54:?ley 9 Wee 4,c 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: S. 5/j•'p lei,
Cell Phone: '5'I`c- "7 V6-O%5 6 Land Line: TA- 79%-%/9 9
Email: -e Sly"p��y ra t b55,7) c .(ow.
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 i C 5. 5 L p/0 y
SIGNATURE: c, y� DATE: 1 c /-as/2V
Septic Alteration Application Revised May 2024
i /
% 1 System Checklist
Septic
Town of Queensbury
742 Bay Road
Queensbury, NY 12804-5902
, 1,G )-c.„,v
gtpicoM
Plan to scale IA - a-o ' ON.`I'd a 4 pi �u r
NA 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)
1'0 All wells on property and adjacent properties shown
tVC Water line shown Municipal or well 10' separation to any part of system
V 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
t
)aterline
r/4 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
NAALeech Field 20'from foundation 100' from any well 10' from water line
Ael' Seepage pit 150'from well 50' from septic tank
r'/Seepage Pits 3-times diameter apart
746 Septic tank and pump stations over 30 gallons 50' from watercourse or wetland
d/a Distance from bottom of trench or system 24" to bedrock or mottling 36"within 1000' of Lake George
II h Leech field 100' from watercourse or wetland
t-i P Toe of mound or bottom of retaining wall 10' from property line, 100' from well, 20'from foundation
7 Provide Engineer/Architect stamp for bed or design systems
"' _ Department of Health Approval for all mobile home park new systems Flood Plain requirements
fr-J°
2' above established flood elevation to bottom of system
All tanks anchored or 2' above flood elevation
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TEAM' '
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scour SCALE
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1m ! 253 Clendon Brook Road
-iVi # Residential Septic Alteration
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