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application SEPTIC DISPOSAL PERMIT Office Use Only DATE Received Tax Map,ID TAX MAP ID ?)Cy\ - Permit No. + �] Permit Fee 855 LOCATION oFINSTALLATION APPLICANT IS+rc�)�"S P4'G Ser 0 <',e- PHONE/E-MAIMi� ADDRESS �Z �I �Sa� ��. :�f� S J�'A ( S M 4 1 RN 0 � �J d INSTALLER/BU/LDER: ��►- `�- �-� R9 �- PHONE/E-MAIL ADDRESS: OWNER PHONE/E-MA k t�)12� Address CONTACT PERSON FOR BUILDING&CODES COMPLIANCE:nar rc._1 tj r RESIDENCE INFORMATION Year Built #of bedrooms X Gallons per bedroom =Total Daily Flow 1980 or older Garbage grinder installed Y V 1981-1991 3 .Spa or Hot Tub installed _Y _N 1992-Present, 3 - PARCEL INFORMATION Topography +Flat rolling Steep slope %slope Soil Nature ��and Loam Clay Other Groundwater . At what depth? Bedrock/Impervious Material At what depth? NS VA Domestic Water Supply ✓Municipal 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.engineering/architect) PROPOSED SYSTEM FOR NEW CONSTRUCTION Tank Size gallons(minimum size 1,000 gallons,add 250 gallons to size for each garbage grinder or spa or hot tub) System Type Absorption field with#2 stone Total length ll(a® ft.;Each trench LI S3 x _ 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&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 &approved. The installed system must match the septic system layout on file—no exceptions. DEcLARAnoN: 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 know.by or on behalf of an applicant,shall be void. I have read the regulations and agree to abide by these and all requirement pf the Town of Queensbury Sanitary Sewage s gsoal Ordina nce. � Print Name: N *� r r -`� Date: 1 Signature: Date: �� 1 Town of Queensb&y Building&Codes Septic Disposal Permit July 2014 Office Use Only d .. SEPTIC DISPOSAL PERMIT APPLICATION Permit#: ,. Permit Fee:$ ; Invoice#: Septic Variance? Yes No Tinrn nf'(jncnabun 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.aueensbury.net Tax Map ID#: Project Location: • Applicant: Name(s): Sit`e*-'►�b. s M a i I i n g Ad d re s s, C/S/Z: SSA Ot , Cell Phone:_(SJ% Lapd Line: Email: Sfi: ,9�,� Se�f: �-e:�o;c� c+rv��% ( �,c� •� • Primary.Owner(s):_ Name(s): -:S"-% 9V:70 1� Mailing Address, C/S/Z: Cell Phone:_( 1� } a3� " 1 �1 � Land Line: _( } Email: ❑ Check if all work will be performed by homeowner only • Contractor: Workers' Comp documentation must be submitted with this application Contact Name(s): ��r�-►C, � � e�` � rJ ` �'� Contractor Trade: ` 1 1 c�,v� •� Mailing Address, C/S%Z: q �ovSSr� .�-i 1� �f��-►5 �-ili t� y I33133 Cell Phone:_(5 t$ ) `�� — ''�$ Land Line: _( ) Email: • Engineer(s): Name(s): Mailing Address, C/S/Z: Cell Phone:_( ) Land Line: Email: Contact Person for Building & Code Compliance: �r r v�� Cell Phone: (S�) S�i- �S '77 Land Line: _(Si%} Email: 'S e 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) All wells on property and adjacent properties shown Ywater line shown Municipal or t �Iation to any part of system YSetback to property lines show 10'or more for any part of system YSeptic 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 Seepage Pits 3-times diameter apart Yl—Septic tank and pump stations over 30 gallons 50'from watercourse or wetland distance from bottom of trench or syste 2 "�bbeclrock 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 Z'-D P .J V—� 0-5c-\o I',-C-- ,Provide Engineer/Architect stamp for bed or design systems J—DDepartment of Health Approval for all mobile home park new systems Flood Plain requirements -P-2' above established flood elevation to bottom of system All tanks anchored or 2' above flood elevation M _ C MEMNON moommommoommoommon MEMO mmmmll w SOMME NEMESES NOON NEMEME ONE�� ■��I11�ir r ►\�� i`il�� '�� SOMEONE ; SOMEONE MENNEN offmamas mo mmomm ■��1�1�11��II��II moommo■ M EMNON Mims so MEN �so�� moommomom 0I11011 NIMMEMENNUMMIN mmorml omm NIMEMME W ONEN NENRIlmoofamomm olllmomms WommmomMEMEMEMEMENEMEME SOMEONE mommm riO�,�000OOOOO�OOOOOOOOOOOO mommm - o - V \ 2 Ir t c �f 5 la EF j JUL 15 .1 TOWN OF QUEENSBURY BUILDING&CODES - AS BUILT