SEP-0464-2021 fT->. SEPTIC DISPOSAL PERMIT Office Use Only
APPLICATION Permit#: Z ' Qek- pA- X2 J
Town of Qneensbnr,v
Permit Fee:$
Invoice#: 2)?)q-1
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.gueensbury.net Septic Variance? Y
Flood Zone? Y N
Wetlands? Y Reviewed By:
Project Location: 13 Lake View Drive
D `,
Tax Map #: 289.8-1-52
JUN 16 2021
RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms: X gallons per =total daily flow TOWN ��QUEENSBURY
per day bedroom 3} No
1980 or older 150 Installed? (choose one) ❑ [Z
1981-1991 130 Spa or Hot Tub Yes No
1992-Present 110 4 110 440 Installed? (choose one) ❑
PARCEL INFORMATION:
Topography Flat Rolling ❑ Steep Slope % Slope
Soil Nature Sand ❑ Loam ❑ Clay ❑ Other, explain:
Groundwater At what depth? n/a
Bedrock/Impervious material At what depth? n/a
Domestic Water Supply ❑ Municipal V Well ❑Lake
(if well or lake, water supply from any septic system absorption is
ft.)
Percolation Test Rate: 5:05 per minute per inch (test to be completed by a
licensed engineer/architect)
PROPOSED SYSTEM INFORMATION:
Tank size 1,250 gallons (min. size 1,000 gallons, add 250 gallons for each garbage cylinder or
spa/hottub
System Absorption field w/#2 stone' Total length ft.; Each Trench ft.
Seepage Pit w/#3 stone How many: ; Size:
-Alternative System Bed or other type: 15'x 30' pipe-in-stone
Holding Tank System Total required capacity? ; tank size ;
# of tanks
L
Septic Application Revised April 2021
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): Joan Dobert
Mailing Address, C/S/Z: 13 Lake View Drive Queensbury, NY 12804
Cell Phone: Land Line:
Email:
• Primary Owner(s):
Name(s): same as applicant
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): Stone Installations
Contractor Trade: Excavation/Installation
Mailing Address, C/S/Z: 4305 Route 50 Saratoga Springs NY 12866
Cell Phone: Land Line: (518) 584-1048 -
Email: dean@stoneindustries.com
"Workers' Comp documentation must be submitted with this application"
• Engineer(s):
Name(s): Hutchins Engineering PLLC
Mailing Address, C/S/Z: 169 Havi land Road�Queensburv, NY 12804
Cell Phone: Land Line: 518-745-0307
Email: thutchins@hutchinsengineering.com
Contact Person for Compliance in regards to this project: Hutchins Enaineerina
Cell Phone: Land Line: 518-745-0307
Email: thutchins@hutchinsenaineering.com
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 Disposal Ordinance.
PRINT NAME: G ho mas Hutchins, P.E. Agent)
SIGNATURE: DATE: 6/16/21
Septic Application Revised April 2021
TO THIN OF D UEENSB URY
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
Li-L&Water line shown Municipal or wT�ell 10'separation to any part of system
. Setback to property lines show 10'or more for any part of system
4..?,6 Septic tank and pump stations 10'from foundation 50'from any well/lake/wetland 10'from any waterline
►J _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
I Leech Field 20'from foundation 100'from any well 10'from water line
r► Seepage pit 150'from well 50'from septic tank
J0--Seepage Pits 3-times diameter apart
�ts Septic tank and pump stations over 30 gallons 50'from watercourse or wetland
(1---LAistance from bottom of trench or system 24"to bedrock or mottling 36"within 1000'of Lake George
��Leech field 100'from watercourse or wetland 260
N�Toe of mound or bottom of retaining wall 10'front property line 100'from well 20'from
Foundation
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
Al tanks anchored or 2'above flood elevation