historical information . _
Application for SEPTIC DISPOSAL PERMIT
Town of Queen.sburY /1'
oi
:Dept_ of Comimunity Deve14ment N-rz7' ' Permit NO• .
Building &Coaes 0111C,c
Seiccior-Ati
742 Bay Road Fee Paid S
•Queensbury, NY 12504
Locadon of,properry for installation: // zg,...„,4 y
Property Owner's Name:4Z 2ZI
Property Owner's Mailing Address 0616 ,44:1/ i A/V 7
,e4 2•1..
•
InStaller"s Name:2,„4AZe. Phone # ,F,3 - o
. Number of bedrooms (iftesidential): 3 Total cl2;ly flow:
(residential - compute @ 150 galibdrm.)
Topography: /flat, rolling, steep slope ra of slope
- Soil Nature: sand, tr loam, clay, other /depth:
Ground water: at What depth? feet / Bedrock or Impervious Material: at what depth'?-7‘ feet.
•Percoladon test: not required, :• uired [raze min per inch]
Domestic water supply: municipal, well, other (.1:2
If domestic water supply is a WELL, water supply:from any sepdc absorption is feed
PROPOSED SYSTEM
Septic r gallon (minimum size: 1,00Q gal.).
Tile field: each tench 54 feet / Total system lenuh: K.P2' feet
Seepage pit(s): number of / size eaCb: ft. by ft.
•
•
Size of stone to be used: # I depth or thickms tieet
• .
1--IOLDbIG TANK SYSTEM: (if requited)
• Nu.rta?er of tanks: Size of each: gaildns
Alarm system ai5 aSsocia. ted'eec!aical v.vric..- to be inspected by a cer^dEod apacy.
For yotn-prbtectinn, please note that pursuant-to Section:136-29 of the Code Of the Town of Q6eensixtry, aay permit or
appro,..4 premed Nikki'is based up?a or is granted is reli,.. co upon am material reisrcpresecca or failure to pas/co
nutter:21 fact or circumstance mown by or on behaif of an ap 1iciu , wail he
I have read the regulations with respect to this application abd agree to abide by thcao and all requirrnaects of the Town of
Quecnsburf Sanit'ary Sewage Disposal Qat:name.
Signature of responsible perss: 'Date:
V„jir
1- st known repairs/replacements,with dates:
Date Type of Repair/Replacement
Nono
Operation:
• System problems? Yes X No
• Sewage odors? Yes X No
• Direct surface discharge(s)? Yes X No
• Back-up of toilets? Yes X No
• Back-up of any other fixtures? (e.g. slow drains) Yes X No
• Seasonal ponding or breakout of leach field? Yes X No
Statement of Acceptance of Conditions:
I agree to:
• Ensure that the septic tank(s),distribution box(es), and/or seepage pit(s), if any,will be uncovered
prior to the requested inspection time;
• Have a septage hauler on site(to pump the tank after*the inspector verifies flow from fixtures);
Tank must be pumped in presence of inspector
• Have an authorized representative present at the site;
• Allow the inspector to verify information provided above, and to conduct an inspection of the
indicated onsite wastewater treatment system(s),including all system components and interior
plumbing in crawl spaces and basements.
To the best of my knowledge,the information provided above is accurate and I acknowledge the following:
After 1 year from date of submission and there is no activity on this permit, the permit will expire and will be
subject to submission of a renewal application and payment of the renewal fee based on the current fee
schedule. All fees must be paid PRIOR TO SCHEDULING any inspections. In addition, if the permit is
withdrawn 20%of the fee is retained by the Town of Queensbury.
Signature of property owner or authorized agent
Please print name: Van Scheid(Lake House, LLC
Affiliation: owner agent
Signature: Date fj/,� --
Prior to scheduling with the Town of Oueensbury, you MUST:!
1. Schedule a sewage hauler to be on site to pump tank while inspector is on site.
Hauler should arrive 30-45 minutes after scheduled time with the Town of Queensbury's
Code Enforcement Officer.
2. Expose inlet and outlet of septic tank, and/or pump station, expose d-box, expose
any seepage pit covers.
3. Excavate test hole in leach field if there is no d-box.
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FEB 2.8-2000 :
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TM OF QUEENSBURY ..d_
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BUILDING &'CODE'ENFORCEMENT. 0
-531 Bay Road
Queensbury NY 12804.
518-745-4447.
SEPTIC DISPOSAL SYSTEM INSPECTION
Name ,....\,\
_`
e
Location -
Date3--_.i...,c_ . Permit # `� 3a.
r .-,t .
SOIL TYPE: :Sand;Lo C1 ay- _
Results o' rcolati on Test-•.
(if. applicabl ) Rate-Minute/Inch
TYPE OF S,S
ABSORPTIs FIELD: Total Length / d`t3.
Length .of -ac , trench .?5' •
Depth, .of .t eeches --'3
Size of sto-e f. . .
SEEPAGE P Plumber-:
Size - ft, x ft.
Stone•size
PIPING: Size. Type . .
Bldg:. to Tank ='> r e .c.;L
Tank to Dist. Box
-- ' 3 _Dist, Box to Fie d/P't Li G. S _
Openings. Sealed? es No .,Partial
LOCATION/SEPARATIONS;
Foundation to Tank ' /c feet
Foundation t' Absorption '. feet
Separation or'. 'P,its fegt_
•Conforms as per Plot Plan Yes (No)
LOCATION' OF SYSTEM ON. PROPERTY:
' (circle opteti
Front Rear- Left Side. Right. Side
Middle Front:--',Middle Rear -
COMMENTS: .
'. � I .
/4',2-"..' ��
•
SYSTEM USE.APPROVED: YES NO` . _
Arrived: . . 't.
Departed: .
Di-
Building Inspector