SEP-0515-2021 SEPTIC DISPOSAL PERMIT office Use Only
APPLICATION Permit#: 5e ► 051.5 — 2JQ21
Town of CZccusbury e�
Permit Fee:$ Vyy� -
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Invoice#: �)
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.gueensbury.net Septic Variance? Y N
Flood Zone? Y
Wetlands? Y ReviewedVBy:
Project Location: —
EC Q '�
TaxMap #: --
JUL 06 2021
RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms: X gallons per =total daily flow TO OF QUEENSR1 I
perday bedroom G & COG.=S-es o
1980 or older 150 Installed? (choose one)
1981-1991 130 Spa or Hot Tub Yes No
1992-Present 110 Installed? (choose one) ❑
PARCEL INFORMATION:
Topography Flat Rolling ❑ Steep Slope % Slope
Soil Nature Sand ❑ Loam ❑ Clay ❑ Other, explain:
Groundwater At w at depth?
Bedrock/Impervious material At hat depth? AL
Domestic Water Supply EVMunicipal ❑ Well ❑Lake
(if well or lake, water supply from any septic system absorption is
Percolation Test Rate: N—5 per minute per inch (test to be completed by a
licensed engineer/architect)
PROPOSED SYSTEM INFORMATION:
Tank size U) gallons (min. size 1,000 gallons, add 250 gallons for each garbage cylinder or
OT"") spa/hot tub
System Absorption field w/#2 stone Total length's ft.; Each Trench._ ft.
Seepage Pit w/#3 stone How many: ; Size:
Alternative System Bed or other type:
Holding Tank System Total required capacity? ; tank size ;
# of tanks
Septic Application Revised April 2021
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): Q�
Mailing Address, C/S/Z: _�Lr(�v QC Vv G�lLf! 544 q�
Cell Phone] -' Land Line:
Email: b� ` S C = f 9�`
• Prim r Owners :
Name(s): rAs (A S(,0-,9-
Mailing Address, C S/Z: Lo m 6-e(+ or-
Cell Phone: 51 Y� Land Line:
Email:
❑ Check if all work will be performed by property owner only
• Contractor: c C
Contact Name(s): J v,) f c
Contractor Trade: y-, Ufa I f
O�y
Mailing Address, C/S/Z: "Z LAW e( W SPYOi �1 Y Cr p(I
Cell Phone: �l i- Land Line: �i « 1 p 7 n"(1 1 7"1
Email: &:f 11 n i 0 ON
**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 Compliance in regards to this project: CYnt,� f)ej�" I eJSc_.
Cell Phone: Land Line: (ii1
Email:
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. 4. If, for any reason, the building permit application is withdrawn, 30% of the fee is retained by the
Town of Queensbury. After 1 year from the initial application date, 100% of the fee is retained.
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 Disp
osal Ordinance.
PRINT NAME: C OfO 'r l6�lzI
SIGNATURE: 4, /01, DATE:_ y U V
�� I
Septic Application Revised April 2021
TOWN OF QUEENSBURY
742 Bay Road, Queensbury, 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)
It wells on property and adjacent properties shown
Water line show Municipa or well 10'separation to any part of system
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 waterline
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)
Septic tank sized for number of bedrooms and add 250 gals for Jacuzzi tubs/garbage grinder each
`( Leech Field 20'from foundation 100'from any well 10'from water line
Seepage pit 150'from well 50'from septic tank
ls)NSeepage Pits 3-times diameter apart
Septic tank and pump stations over 30 gallons 50'from watercourse or wetland
distance from bottom of trench or syste 24" edrock 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
p� Foundation C- N J C i�\A
"
1 Provide Engineer/Architect stamp for bed or design systems
Department of Health Approval for all mobile home park new systems Flood Plain requirements
--�-2' above established flood elevation to bottom of system
1Jf� F�-Oov
All tanks anchored or 2' above flood elevation
r Town ee Interactive Mapper
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Rascoe, Thomas
63 Lambert Dr
Residential Septic Alteration
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