SEP-0526-2021 t „_ e:.:......
Ilk-
Office Use::On1G:.
Permit.#:
Permit Fee:$.. . ..
NY:12804
:::iPc 5T8=761 8Z56. w+aw.ttueensbw met:.. ... nvoice.t,
Y Reviewed -
F(ood.Zpne? /:N) R few �:By: MS
SE°PTIC D15POSAL'RERMiT aPPIICAT��3N Ycw � . �
�� �v
Pra ec J :a.Location:
U W IE
P ' Z 0 —l� a
TaX � : :
TOWN OF QUEENSBURY
BUILDING& CODE
: RES.ID:ENCE'.INFORMATION s
Year<Buift.: Gallons #of bedrooms:- X:gallons per: =total daily flow.
per:ciay..._ : bedroom Garlaage;.:Grir tler Yes: No
--
1980:o'r.older 150 1 �; talletl?.(cirele;one}.Ins
1- 801=1991 1 0: Spa or Hot Tub Yes o
1992713resent 110 d? :(circle one}
Insfialle
PARCEL:INFORMATION:.
Topography .. .lat Rolling Steep.-Slope..% S1Qpe.
.......
Soi :Nature joa,m Clay Qther, explain;,:
Gro.uodwater: At.w; t:de .th?
Be ro:ckJl°mperuious material.. .At: at depth?
aomestic;:WatierSupply. _�Avlunicipal. _Well:
:
(if well or lake,water supply.from any septic system absorption is.
ft.)
erco.ation Test; Rate; p.er minute per inch (test:;to be:completed by
....... 'liicensecl:engineer architect)
RO .
P POSED;SYSTEiVI:'INFORMAT10M
-ankai2e gallons (min. size.1;000.gallons, add:2S(1 gall ns for each:garbagp:.cylinder car
spa/hot,tub
. :: :System:' Absorptir�n field:w/#2 stone Total length ft;;: EachTren�h:.:. .._-_ ....... ft,.
See :stone�a e:Pit w How:mari ::
� 1 v
Alternative 5:ystem: Bed orother:-type
:
Holdin Tank S 7
g ..ystem Tota require capacity. ;_tank size:.
l
# of tanks
SepticAppl otion Revised December 2'020
�.... ...... .
CONTACT.INFORMATION PLEASE.PRINT LEGIBLY.OR.TYPE, PLEASE IN:CLU,DE AN EMAIL
.. ...... ... ..... . .
�. A... ... ican
�.
illlaili.rig Address C1S/Z: f ir►
—�
C:ell`Phari :I ):. Land:Line: _( )
�.
Email; �
• Prirrra '. :.O.caner s ::
:Name(s) , ........ n _......... Malling:Addt- s C/SJZ fir..
........ ... . .......
CeII:Phone:. Land:Line:: _( )
Errrail:
O Check l f:all work will. be.performed by property:owner.only
:•:: ..;Contractor:: � � � �
Cdnfiact Names <
( ).
Coritractior Trade.: ! Q�
m ilih :Address /S Z:.
"
Celt Phone: ( Land.Line:
Email: . ' . ... .
.._ . . . .::.. .... ............ .. .
:*1Norker ':Comp docurrr�entatit�n .must:be subrnttd:with hisapplication `*
•: En sneer s
Name
IS
IVfailirig Address. c/s/z: .. .
...... .... ......
Cell.P.hon.e:. .( } Land Line:: _(
Email: _...... ... _ ...... . .....
Contact Rerson:for:Compliance in;re rds.to this project: .
0/7VY5.....�L .
Cell Phone: : )` ,1-2.` Land Line: i
Email
NOTES;:1:Alarm::system and ass:oclated: lectrical wor.::mustte::inspect:e6 y:a:Town approved el'ectr.icat
i:nspectign:agency;,2.�:We will na longer allow systethsA6 be:covered.; nti[such.ti:me as:an as=taus)[:pian:Ji.
received ......pproved.The installe.daystem m.. st match the septicaayout.on file--no:exceptions. 3.:;As
bait[<drawidgs must,:be submitted prior ta;the:inspectic n i.f there has been:a chahge:to thi=submitted
...
tans 4 if`f
p.. ,:. .; ..:.....;<:.or any reason;fhe building„permit appi�cafion,is withdrawn,.3.0°%':o,:t 'efee_ s.reCain.ed: .y the
T.ow.n.'of U*eeri bury.:After 1 year from the initiat`application date, 100°l.of the fee s r+etained..
.:Dec aration::An:y permit:or approval granted is based:upon:or is:granted.in reliance uponany;materlaf
representation orfaElure'fo make a:material fact or.circumstanee known by or on behalf of an .'*' 'I ant,sliall be
void,:1,h***readahe regulations-and::agree:to abide by,these and all.,requirements of the Town of Queensbur:y
Sanfary:Sewage:Dis a :..I.ordinance.
� l
::....::PRINT:NAME:.: ::':.:. 9. ... :. ..
.......:....
.:;::
`!SIGNATU;RE: :::;:;>> '.DAT . ...::.::;. :...:<::.::.: :::.:.:.
Septic Application: Revised:December 2026
TO"KW OF QUEENSBURY
742 Bay Road, Queensbury, NY. 12804-5902
Septic System checklist
Plan to scale
-S 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)
IJ 6 All wells on property and adjacent properties shown— NAJY',i C\ PC. l
Water line shown Municipal or well 10'separation to any part of system
U'GS 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
t4k—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
4—Seepage pit 150'from well 50'from septic tank
4—Seepage Pits 3-times diameter apart
I 'C-� Septic tank and pump stations over 30 gallons 50'from watercourse or wetland
Ic S distance from bottom of trench or system 24"to bedrock or mottling 36" within 1000'of Lake George
bll—gLeech field 100'from watercourse or wetland
iJ Toe of mound or bottom of retaining wall 10'from property line 100'from well 20'from
Foundation
G SProvide Engineer/Architect stamp f V
tJ Department of Health Approval for all mobile home park new systems Flood Plain requirements
WO 2' above established flood elevation to bottom of system
N6 All tanks anchored or 2' above flood elevation
RUCINSKI HALL ARCHITECTURE. ��`'
Ronald Richard Rucinski
Ethan Peter Hall
134 Dix Avenue �JG
Glens Falls NY 12801
Voice 518 741 0268
Fax -518 7410274
Email ephall@nycap.rr.com
1 Park Ave
MacKnight Residence
22.July 2021 0
Town of Queensbury Building Department JUL 22 .
742 Bay Road
Queensbury NY 12804 TOWN OF Ql1EEN
LDING& CO Es
.
Re: Installation of Replacement Sewage Disposal System
At the above referenced project location this office observed the installation of the new septic tank,
distribution box and gravity bed system. This installation is acceptable to this office. If there are any
questions please contact our office to,dlscuss.
Regards, f`' "
-.2024
Ethan ter Hall
Architect
AS B U I LV
1