SEP-0402-2021 4 SEPTIC DISPOSAL PERMIT Office Use Only
APPLICATION Permit#: C1 �2- � -1
Town of yee sn bury Permit Fee:$
Invoice#:
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.aueensbury.net Septic Variance? Y �N
Flood Zone? Y N
Wetlands? Y N Reviewed By:
Project Location: 11 Ivy loop,Queensbury,NY
(main house)
Tax Map #: 289.10-1-26 D E C E U V 2
RESIDENCE INFORMATION: QY 2 7 2021
Year Built Gallons #of bedrooms: X gallons per =total da ly f
per day bedroom N if i r Yes No
1980 or older 150 2 130 260 "�� .shoos 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: cobblestone
Groundwater At what depth? 30 ft.
Bedrock/Impervious material At what depth?
Domestic Water Supply ❑ Municipal ❑✓ Well ❑Lake
(if well or lake, water supply from any septic system absorption is
100 ft.)
Percolation Test Rate:I min 35secper minute per inch (test to be completed by a
licensed engineer/architect)
PROPOSED SYSTEM INFORMATION:
Tank size 1,000 gallons (min. size 1,000 gallons, add 250 gallons for each garbage cylinder or
spa/hot tub (q'1000vseptie=tank.;and=a1;000�effluentpum--pl:chamber)
System Absorption field w/#2 stone Total length 150 ft.; Each Trench 50 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): Doug Miller
Mailing Address, C/S/Z: 4 Stone Pine Lane, Queensbury, NY 12804
Cell Phone: (518) 232-4199 Land Line:
Email: douq@adksc.com
• Primary Owner(s):
Name(s): Doug and Teresa Miller
Mailing Address, C/S/Z: 4 Stone Pine Lane, Queensbury, NY 12804
Cell Phone: (518) 232-4199 Land Line:
Email: douq@adksc.com
❑ Check if all work will be performed by property owner only
• Contractor:
Contact Name(s): Chris Bell
Contractor Trade: IBS Septic & Drain Service
Mailing Address, C/S/Z: 2 Lower Warren St, Queensbury, NY 128,
Cell Phone: (518) 361-2465 Land Line: (518) 7987-8194
Email: mbeckwith@ibsseptic.com
"Workers' Comp documentation must be submitted with this application"
• Engineer(s):
Name(s): Ethan Hall, Rucinski Hall Architecture
Mailing Address, C/S/Z: 134 Dix Ave., Glens Falls, NY 12801
Cell Phone: Land Line: (518) 741-0268
Email: ephall@nycap.rr.com
Contact Person for Compliance in regards to this project: Doug Miller
Cell Phone: (518) 232-4199 Land Line:
Email: douq@adksc.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: Doug k er
SIGNATURE: DATE. 5/26/2 1
Septic Application Revised April 2021
RUCINSKI HALL ARCHITECTURE
Ronald Richard Rucinski
Ethan Peter Hall
134 Dix Avenue �JG
Glens Falls NY 12801
Voice 518 741 0268
Fax 518 741 0274
Email ephall@nycap.rr.com
11 Ivy Loop
Camp system
19 July 2021
Town of Queensbury Building Department
742 Bay Road
Queensbury NY 12804
Re: Installation of Replacement sewage disposal system
At the above referenced project location this office observed the installation of the new septic tank,
effluent pump chamber, distribution box, and gravity infiltration laterals (rated H-20 for traffic area)
prior to backfill. This installation is acceptable to this office. If there are any questions please
contact our office to discuss.
Regard!V, 1.
Ethan Peter Hall
Architect
`'/'? �Cc V'� :'•»/ vim/ H
JUL 19 2021�
AS BUILT TOWN OF QUEENSBURY
BUILDING& CODES
?1-- 02-60
TOWN OF QUEENSBURY
BUILDING & CODS EPT.
Reviewed By:
Gate: -7 P
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