SEP-0063-2021 Office Use Only
Permit#: P 091Q-S- 2C2\
Sa
EPTIC DISPOSAL PERMIT APPLICATION Permit Fee:$ 85' ; Invoice#: '05'h
Town ofQucens6ory Septic Variance? Yes No
742 BaV Road,Queensbury,NY 12804
P:518-761-8256 www.gueensbury.net
Tax Map ID#: ' 1� -521
a � E
EProject Location:
FEB 16 2021
Applicant: TOWN OF QUEENSBURY
Name(s): �s
BUILDING&CODES
— Mailing Address;C/S/Z: '__ - ,-_ - j- r� E P :
Cell Phone:_( )cs ) — � `7n 7 Land Line:,_( ii ' ) ® �s� �m
• Primar Owners :
Name(s): 6 A
Mailing Address, C/S/Z: `�,
�� V
Cell Phone:_( ) Land Line: _( _ 7 � 772
Email: .� r .� ��, �L�.).�—�—�
❑ Check if all work will be performed by homeowner only
• . Contractor: Workers' Comp documentation must be submitted with this application
Contact Name(s): �� �, ,��, p, �--�-dam� I � �cz. %�
Contractor Trade:
Mailing Address, C/S/Z. ";eJ i
Cell Phone:_( _ = 70-7 Land Line: _(�) �� c
Email:
• Eneineer(s): --
Name(s):
Mailing Address, C/S/Z: < ��
Cell Phone:_ . Land Line: _( )
Email:
Contact Person for Building & Code Compliance: )1e,el,ki
CelI Phone: _( ) Z— Zr 6 Land Li e: _( l
Email: ef,eG 2 ,M
Septic Application Revised February 2019
y
RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms: X gallons per =total daily flow
per day bedroom Garbage Grinder. Yes o
1980 or older 150 Installed? (circle one)
1981-1991 130 Spa or Hot Tub Yes o
Installed? (circle one)
1992-Present
PARCEL INFORMATION:
Topography Flat Rolling Steep Slope %Slope
Soil Nature Sand _Loam _Clay _Other(explain: )_
Groundwater At.what depth?
Bedrock/Impervious material At what depth?
Domestic Water Supply XMunicipal —Well (if well,water supply from any septic system absorption is ft.)
Percolation Test Rate: per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size DSO gallons (min.size 1,000 gallons,add 250 gallons for each garbage cylinder orspa/hot tub <
System Absorption field w'`'.rrR-stere Total length ft.; Each Trench ft. S
Seepage Pit with#3 stone How many: ;Size:
Alternative System Bed or other type:
Holding Tank System Total required capacity? tank size ;#of tanks
NOTES: 1. Alarm system and associated electrical work must be inspected by a Town approved electrical inspection
agency; 2.We will no longer allow systems to be covered until such time as an as-built plan is received and
approved.The installed system must match the septic layout on file—no exceptions. 3. As-built drawings must be
submitted prior to the inspection, if there has been a change to the submitted plans.
Declaration:Any permit or approval granted which is based upon or is granted in reliance upon any material
_r_epresentation-or-fail ure 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.
n
PRINT NAME: f✓� J c-- DATE:
SIGNATURE: DATE:
Septic Application Revised February 2019
John O'Brien
From: Dave Hatin
Sent: Wednesday,February 10,2021 3:01 PM
To: John O'Brien;Charles Dyer,Mark Smith
Subject: FW:Forest Park MHC-#7 Timber Ln.
This for one of you?
FILE C®Py
Director Building and Code Enforcement
Town Of Queensbury
518 761-8253
daveh@queensbury.net
From: Kenyon, Kevin J (HEALTH) <kevin.kenyon@health.ny.gov>
Sent:Wednesday, February 10, 20212:33 PM
To: Ryan Riper, PE<RyanRiper@RKenginee ring.us>; 'DEAN BURDICK-STONE INDUSTRIES' <Dean@stoneindustries.com>
Cc:tschrammel@rhp-properties.com; Dave Hatin<DaveH@queensbury.net>
Subject: RE: Forest Park MHC-#7 Timber Ln.
I approve of the emergency replacement. As discussed, submit as builts to our office when the system has been
installed.
Kevin J. Kenyon, P.E.
Professional Engineer I
New York State Department of Health
Glens Falls District Office
77 Mohican Street
Glens Falls, NY 12801
Phone: (518)793-3893; Fax: (518)793-0427
kevin.kenyon@health.ny.gov
From: Ryan Riper, PE<RyanRiper@RKenRineerinR.us>
Sent:Wednesday, February 10, 2021 1:39 PM
To: Kenyon, Kevin J (HEALTH) <kevin.kenyon@health.ny.gov>; 'DEAN BURDICK-STONE INDUSTRIES'
<Dean@stoneindustries.com>
Cc:tschrammel@rhp-properties.com
Subject: Forest Park MHC-#7 Timber Ln.
emailATTE]VTION.- This ssource. Ii not open attachmenis e on i iwn senders or
unexpected einails.
Kevin,
It was discovered today that the system that was replaced for the failed septic at#9 Timber Lane in
April of 2020 at Forest Park MHC had an additional home (Lot#7) connected to the system.
Apparently there was an unknown wye connection between home #9 and the septic tank.
Recently the line out from home of Lot#7 has been plugging up and creating back-ups. There is no
septic tank attached to Lot#7 at this time.
i
With youf%pr6val, Dean at Stone Installations will install a 1000 Gallon Concrete septic tank for Lot
#7 and follow up with the installation of laterals. I will direct the required installation design, perform
an inspection and follow up with an as-built to your office.
Please let us know at your earliest convenience if you approve of this emergency replacement.
Ryan K. Riper, PE
RK Engineering, PLLC
Cell 518-817-0099
2
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