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SEP-0628-2020 SEPTIC DISPOSAL PERMIT office Use Only • APPLICATION Permit#: - oto2$• 2®2o Town ofQueensbury Permit Fee:$ Invoice#: 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.gueensbury.net Septic Variance? ©Y N 150VV 654},2CZp Flood Zone? Y (l Wetlands? Y A Reviewed By: S Project Location: C,:: D LE 0 V IE Tax Map #: 2 _-7 — 6 — ��, SEP 0 6 1012 RESIDENCE INFORMATION: TOWN OF QUEENSBURy Year Built Gallons #of bedrooms: X gallons per =total daily flow BUILDING&CODES per day bedroom Garbage Grinder Yes No 1980 or older 150 Installed? (choose one) ❑ ✓� 1981-1991 130 Spa or Hot Tub Yes No 1992-Present 110 Installed? (choose one) ❑ Lvi -LL� PARCEL INFORMATION: Topography ❑ Flat Rolling gSteep Slope ff�_% Slope Soil Nature Sand ['Loam ❑ Clay ❑ Other, explain: Groundwater At what depth? ;� Bedrock/Impervious material At what depth? > C,' Domestic Water Supply ❑ Municipal ❑ Well ZLake (if well or lake, water supply from any septic system absorption is ft.) Percolation Test Rate: 175 per minute per inch (test to be completed by a licensed engineer/architect) PROPOSED SYSTEM INFORMATION: Tank size T5 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: Alternative System 'or other type: F-4-J 'S' es -4' Holding Tank System Total required capacity? ; tank size "T- L' # of tanks Septic Application Revised July 2022 F CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL a • A plicant• :� Name(s): �' Mailing Address, /S/Z: (0 1 �_�.�► � �� `� �Z � Cell Phone: Land Line: Email: • Primary Owner(s): Name(s): Mailing Address, C/S/Z: Cell Phone: Land Line: Email: ❑ Check if all work will be performed by property owner only • Contractor: Contact Name(s): Contractor Trade: -,r5 tit: _ Mailing Address, C/S/Z: (c=;j V1 Cell Phone: 'mil$ 1J-7O—,,x-$ Land Line: Email: **Workers' Comp documentation must be submitted with this application** • Engineer(s): f�"'>_1,Vt �'� � � Name(s): Mailing Address, C/S/Z: l 1 Z 15LxjA �"d—--M_A,% _ �c�+-> jKSi`f t�,�{ mee Cell Phone: _'5Ve5 -,5?&-A4A4&>5 Land Line: Email: C-CSVYN. Contact Person for Compliance in regards to this project: ' Cell Phone: _2_ l E5 c- 75 74V'A+12M5hd 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 ( SIGNATUR • Ln DATE: Septic Application Revised July 2022 T0 N OF QUEENSBURY 742 Bay Road, Queensbuny, NY. 12804-5902 Septic System Checklist "Plan to scale 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) N6 All wells on property and adjacent properties shown f O/ Water line shown Municipal or well 10'separation to any part of system Wletback to property lines show 10'or more for any part of system "(b -IeA/n Cam/ �- Jeptic tank and pump stations 10'from foundation 50'from any well/lake/wetland 10' from any waterline ti.ASeptic tank to foundation crawl space/slab on grade,grade in crawl space must be above top of septic tank p� _ �for 0',Separation required (field verification required) "Septic tank sized for number of bedrooms and add 250 gals for Jacuzzi tubs/garbage grinder each 6��eech Field 20'from foundation 100'from any well 10'from water line t- Seepage pit 150'from well 50'from septic tank 4JA eepage Pits 3-times diameter apart -L�Septic tank and pump stations over 30 gallons 50'from watercourse or wetland distance from bottom of trench or system 24"to bedrock or mottling 36"within 1000' of Lake George Leech field 100' from watercourse or wetland Toe of mound or bottom of retaining wall 10'from property line 100'from well 20'from Foundation t''�Provide Engineer/Architect stamp for bed or design systems 0 Zq,Department of Health Approval for all mobile home park new systems Flood Plain requirements 2' above established flood elevation to bottom of system IJ6 All tanks anchored or 2' above flood elevation Revised 4/15/2021 (D O W r-r 7C Q' W n' ::3 O V 0 < x CL d N n ? d XF D � rD �m rt O N 00 N N 0 z nj C m r m @ � 5— CD r o � o R-acn Gn w � c- 0 =3 co z co CD (D p Z -20 0-n 00 w me --Kirn 00� XZ no --i co 0- co CD o rnG O N 215 iJQQ =3 w o o�N@ cA Do Zp o `� G 90m ,N C u e T cn m U'i4.'ibWNt-Ai 0 0 T r m 0V)mn0 I m <> zn=G) z-"'-i 0 =� m O z V) 1 7� D o m �• < rn n V) �� z D D m m Z N O m m D O;r, Am O m r) (D zd a � � c� > rd �o � d � �O O d tTj r�tTj tTj z�o dtTj 0 ntTj x U) m (n m cn D W ROPOSED WASTEWATER IMPROVEMENTS,�� \ % — t y 0 KAHANfi 0 r- (n cogu1 o - RESIDENCE .� = 0 ENVI ONMEN.TAL DESIGN m 61 KNOX ROAD WARREN COUNTY PA ,NERS#� z \ D TOWN OF QUEENSBURY NEW YORK 20, 2020$?'�'� �� r 900 k8ute �ix46 Gliftar� Far -; 'New York-1206 ��f p'°"' TAX MAP. 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NO. 239.7-1-12 JANUARY 20, 2020 ),V14621 �' `�if "-map"P°"' R:\WARREN\QUEENSBURY\KNOX ROAD\61 - Kahan\05 - dwg\Detailed\02-SPLN-KAHAN - R3.dwg Sep 07, 2022 09100146AM, �m o N m Z < D O n x momvn O ZOO 9Q�i N mp_ x x cn it mm W �-jO�N� 0*-?��*r71 PZZ:Tl—D 2' D 0 —ml Z O .p m v) ro O A —Tl N rn -n :n� <�' Cb I J C1J 41& ' Z C) N T n D r m z H 0 n p ri �omm gm�$ mm o 'A rn A m� N_ Tavm V _ D ZZ �+�1 O 7ZC p r .� N m z m t J i z C D Ag � v �m0 Dr0 Z D D Z � 5 a v m 0 2p Z � m my� '•1 o 0 N �^Dz z FFiiO••���i Fn A z v z U) m x Z Z N m 0 A Z N m z � v oAw zO . a) N y` =1 zS� OmN rZ ry Zp ZAS I8oi2= " �f R'ZO 7C ANZm_ v O� °°r° a°° ftP e !E i e Q 9 - 'J 19 - 121 O v °°°°° O X L �j __ 6 All N. CL iaa =g 3 Q_ io ED Aj 0 PROPOSED WASTEWATER IMPROVEMENTS�- D 0 0 o KAHAN �\ o 0 o1 RESIDENCE,: 61 KNOX ROAD TOWN OF QUEENSBURY TAX MAP. NO. 239.7-1-12 WARREN COUNTY NEW YORK JAN UARY 20, 2020 A L4 L4 bwl L4 (A ILA L-4 to L4 Lq (A (A CA to CA L'a W LA LA (A (A .01 -N -N -N .96 Ul Lyl L" 0 to cp CA to to CA m O 01 to 0) (7) LA a) -4 OD ILD 0 — III L4 -N 0 (7) -4 OD tD 0 La to jail III ;d III S2 ZO zo "Z 7 izi 28 zz > m 0 PROPOSED WASTEWATER IMPROVEMENTS § -4 cn 0 0 > cj) co :E KAHAN m 0 X -0 0 --1 z 110 0 Ln RESIDENCE ��� �f �; r- Z IE: YRONMENi DESIGN, m m , �\ i / a 61 KNOX ROAD WARREN COUNTY PART�F�Rp, lHlIlK-_- m TOWN OF QUEENSBURY NEW YORK 7 o 900,Rout046 '1 2065 > j �1,8) VI-7621 TAX MAP. NO. 239.7-1-12 JANUARY 20, 2020 § i dpllp;com m'-c ENVIRONMENTAL DESIGN Oct) PARTNERSHIP, LLP. 900 Route 146 Clifton Park,NY 12066 (P)518.371.7621 (F)518.371.9540 edpllp.com Shaping the physical environment June 26,2023 Town of Queensbury Building &Codes I y } 742 Bay Road Queensbury, NY 12804 4 JUL 31 Attn: John O'Brien, Director .a• Charlie Dyer, Code Compliance Officer TOWN OF QUEENS 3LJfR BUILDING&CODE'S Re: Kahan—61 Knox Road Replacement Wastewater System Dear John and Charlie: In compliance with application approvals granted by the Town of Queensbury I offer the following regarding the referenced project. The design plans, prepared by this office, reviewed and approved by the Town as associated with the wastewater system application,are as follows: Proposed Wastewater Improvements For The Kahan Residence Applicant: Roberta Kahan 61 Knox Road Town of Queensbury January 20,2020 Revised Sheet 311 November 4,2020 • Sheet 1 —Cover Sheet • Sheet 2 —Existing Conditions • Sheet 311—Wastewater Plan with Variances • Sheet 4 -Details • Sheet 5 -Absorption Field Profile During the course of construction I was on the job site to observe key components of the system installation. The field location of the grinder pump tank,the 1500 gallon septic tank and four Eljen GSF laterals have been installed as per the approved design plan. I have provided an 'as-built' plan which indicates those locations with `tie distances'to the buried d-boxes. All aspects of the work were constructed as designed and using the materials as specified. The grinder pump system was set up for operation (float controlled)and tested/inspected on May 271n. Based on my inspection of the system installation it is my opinion that the wastewater system is in compliance with the intent of the approved design plan and is ready for operation. Sincerely, _ rA^c _y Dennis MacElroy, PE Attachment Cc: Roberta Kahan n� � mmmo o E`oO�aA zm oa TZ 2y �m 2 y Z;Orcaj bto m°z 22� 0)2 iz Amy I a cm m mo�01 2Z �n r�yo�oa om mcmy� 22 o AI C-�m Zy ,n�2Z tiU1 ot�n2~ 2 C4zOA,,OD to° zn ynn rra mcnm � �yo(,Aok2 o ''z°Cn M -, C) E0 "�I�n �(�i3O n -0anm?Mi, Zoo z�� a m°vm2�A as �o°m z O$2 -40 ul�� my A$A °r�e c:u A m�Z -c tmi3O� �3 A U mrC20�0 �Om�t,E, 2a tnp~ mco L� o m zt m°Zo ~am�oyi x° 1mZ mz mo,a0w so om crn° om�i°mi �m mho n -1 0 cmma3mo ft,v, � r- ; Z o� Nxz a x ^C 4N A yc2�m*1m0 �� O A ''•j `� A13--00Zoo= 00 p U 0 22a-4 y m (n 0 min°omn r ° sR 11 x a 44 s,< TT a o D 0 2 E n o D r n ra- A mz o N � am m 0 O'ymy�XZ oi�imo2�m �xp�aa b a rn o��zayo xm�mOOyymQ am�o�MIA om,zz�iz�° rti zc�c�z- yo r�*t mpQIq $o-n O�yZ�cnny ;k rq <Do• °�'�z 2y�m��ca -C= rr�ir -u°i-rmAomma ,om�zm0� � a�cn a2 O arm O omo m o0 a 333 334 - 335 —338 —'-340- �aa p 0'y0 mm� mom 2y z UFO-2r2 mma� m O� =o °m 002k082 ay ��a p pis o mx,�A�o� xm �mpo�°ci zcZiob��y No a� 'Z p 2 z O i a a a n m Amm m �Zo ------ In °mo �^{� 1 0 O ryln A m.0 j ;+ zxo z n 0 ymy0C2C Z3 a } cob 1' a- 3 W m O r 7 4' o = mmo cn O Ni A roA -51 R, $' rgia C y m ryr W D�J;n Z 2m � ti0 cn T- o y � mxa ram- J � O � O ti A2si 2oa 0 w `h m u� `F , 1 { 9paa 1, P � t _ " R.r- 9 PROPOSED WASTEWATER IMPROVEMENTS -rrij z m D 0 pm KAHAN apm wEn E to 3�RESIDENCE o m n D o 7z, m m 61 KNOX ROAD WARREN COUNTY TOWN OF QUEENSBURY NEW YORK a o m TAX MAP. NO. 23q.7-1-12 JANUARY 20, 2020 0 0 o m s mm r MI ti � Z O _ Q m � N o D r r (rl 0 a r a b u MI Zo mm r MCA Om ZO v m a mo =1 n m� N a vm o> m z o �1 m c.o -q mmi5 Ogr.mm m n N F�00 zOxc o;0-+o 3 z i 0 J 00-V 0 v NNO rq m otay �O �•m zoos` ^ �ma o AZ Sm tN� 1gN ��g 'D 0m W oSns " i (�.ZO �pZ AD m me �_tlA-m a mNz 10 co.. m x x N lk 01.1 ❑o®o■o0 as z o® o ag + oopaT a'= !AR IF oawl) X N• i 6 C Nso � 4� ol g 13 0 130fi0b 4 e _ o I ❑oaN I 'e IF a ' '::4 g < P e r c ®� "' "� a I— — a"a@ :gs a 3= ss s n' pE v R g 3 �avcs S o m #_ a o _ O n •< m 3' PROPOSED WASTEWATER IMPROVEMENTS f �f „, KAHAN =i` RESIDENCE Em • 01 TOWN OF QUEENSBURY a4— -t TAX MAP. NO. 239.7-1-12 WARREN COUNTY NEW YORK JAN UARY 20, 2020 a SEPTIC VARIANCE Office Use Only WL Received: APPLICATION Permit Town of Qgccnsbury Permit Fee: 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.gueensbury.net Invoice#: Approvals: Submittal: I (one) original &8 copies of the completed application package Property Owner(s): Roberta Kahan Owner's Agent: Dennis MacElroy Address:61 Knox Road Address: 112 Sunset Trail Lake George, NY 12845 Queensbury, NY 12804 Phone#: 518 656-9489 Phone#:518 792-8200 Site Address: 61 Knox Road Tax ID#: 239.7-1-12 Directions to Site:Assembly Point Road to Knox Road, #61 Distance from well on property to septic system (if applicable) NA feet Is it possible to install a conforming septic system on this property? ❑ Yes N No If YES,please explain and attach a diagram:Click or tap here to enter text. Does the proposed system meet setback requirements for distance from wells&septic systems on neighboring properties? N Yes ❑ No If NO, please explain: Click or tap here to enter text. Is the proposed system to be installed under a parking area? ❑ Yes N No Section of the Sanitary Sewage Ordinance from which you are seeking the variance (i.e. leaching system will be 89 ft. from well in lieu of required 100 ft.): Section 136-9 D :Table 1 Horizontal Separation Distances V-1 : Absorption field setback to southside property line—proposed at 2'vs. 10' required V-2 : Force Main piping setback to northside property line—proposed at 5'vs. 10' required V-3 : Effluent line piping setback to northside property line—proposed at 5'vs. 10' required V-4: Septic Tank setback to northside property line—proposed at 3'vs. 10' required � I C� 0WE OCT 13 2020 TO; iN OF QUEEN! u'JRY Septic Variance Application BUILDING&COU!sed Febru ry2019 List the names, parcel addresses, and tax map numbers of all adjoining property owners. You may obtain tax map numbers from the Assessor's Office as well as the names and addresses: North Name Robert Glandon 3 Address 6.fKnox Road Tax Map ID 239.7-1-13 South Name Penelope DeRocker Address 53 Knox Road Tax Map ID 239.7-1-11 East Name Carol Collins Address 62 Knox Road Tax Map ID 239.7-1-39 West Name Lake George Address Click or tap here to enter text. Tax Map ID Click or tap here to enter text. OWNER STATEMENT I/We do hereby relieve the Town of Queensbury from any liabilities on the plumbing and septic system located at: Click or tap here to enter text. I/We realize that putting the well, septic tank or leaching system less than the required_feet from the Click or tap here to enter text. may increase the risk of pollution. Owner—Print Name: Roberta Kahan V-pjb1-,4J Date: (o J5__Z__0?_0 Owner—Signature: r�o` � �—w -- - Date: lD s NEIGHBOR OR TENANT RELEASE STATEMENT (if applicable) I/We do hereby relieve the Town of Queensbury from any liabilities on the plumbing and septic system located at:Click or tap here to enter text. I/We realize that putting the septic tank or leaching systemless than the required 10feetfrom the 4e*4@4. may increase the risk of pollution. Neighbor/Tenant—Print Name: Date: Neighbor/Tenant-Signature: Date: Septic Variance Application Revised February 2019 AUTHORIZATION AND SIGNATURE PAGE This page includes the Authorization to Act as Agent form, engineering fee disclosure, authorization for site visits, other permit responsibilities and agreement to provide documentation required. Complete the following if the OWNER is using an Agent: Owner's Name: Roberta Kahan Designates: Dennis MacElroy as agent regarding the Septic Variance for Tax Map#: 239.7-1-12 Q ✓ n-JOWNER'S SIGNATURE: �GU C_W-__ DATE: 1 J AO Engineering Fee Disclosure:Applications may be referred to the Town consulting engineer for review of septic design, storm drainage, etc. as determined by the Town Board of Health. Fees for engineering review services will be charged directly to the applicant. Authorization for Site Visits: By signing this page and submitting the application materials attached herein,the Owner,Applicant and his/her/their agent hereby authorize the Town Board of Health, building and code Enforcement Officers and Town Engineer to enter the subject properties for the purpose of reviewing the application submitted. Please Note: Other permits may be required for construction or alteration activity subsequent to approval by the Town Board of Health. It is the applicant's responsibility to obtain any additional permits. Official Meeting Minutes Disclosure: It is the practice of the Town Board of Health to have a designated stenographer tape record the proceedings of the meetings resulting from the application, and that the minutes transcribed from those tapes constitute the official record of all proceedings. If there is a discrepancy between such record and the handwritten minutes taken by the designated stenographer,the handwritten minutes shall be deemed the official record. I,the undersigned, have thoroughly read and understand the instructions for submission; agree to the submission requirements and completed checklist: OWNER—PRINT NAME: Roberta Kahan rr .OWNER—SIGNATURE: ��� � 1'�4�1—DATE: October 3,2020 AGENT—PRINT NAME: Dennis MacElroy AGENT—SIGNATURE: M c- DATE: October 3,2020 Septic Variance Application Revised February 2019