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Application SEPTIC DISPOSAL PERMIT office use only APPLICATION Permit#: tC—P' O(o.3--- Za2) Permit Fee:$ 8� Invoice#: �t)Z`J 742 Bay Road,Queensbury,NY 12804 �,� P:518-761.8256 w_w_w.queensbury.net Septic Variance? Y N 1 Flood Zone? Y Wetlands? Y eviewed Project Location: e- L o�' 3� �` V � �7 Tax Map #: gigR, RESIDENCE INFORMATION: Year Built Gallons #of bedrooms: X gallons per =total daily flow per day bedroom Garbage Grinder Yes No 1980 or older 150 Installed? (choose one) ❑ 29 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 what depth? Bedrock/Impervious material At what depth? Domestic Water Supply K Municipal ❑ Well ❑Lake (if well or lake, water supply from any septic system absorption is ft.) Percolation Test Rate: 'per minute per inch (test to be completed by a licensed engineer/architect) PROPOSED SYSTEM INFORMATION: Tank size Ji0c0gallons (min. size 1,000 gallons, add 250 gallons for each garbage cylinder or spa/hottub °y System Absorption field wA$42 st Total length JJ0 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 nl i G I �Septic Application I I Revised April 2021 CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL • Applicant: f/l Name(s): r o✓I0.1Ms Mailing Address, C/S/Z: r ,�craS �•S%�CcPu'��j�� Cell Phon : �e -Z�Z 70'7 Land Line: S/R Email: eCcwr/15� ,7e,i"J CC:5v>+ • Primaw gWrieffr(s) Name(s): a iS Mailing Address, C/S/Z: Cell Phone: 7 Land Line: Email: ,. / Ur - �/UQrs �;r{i,t �✓✓+ ❑ Check if all work will be performed by property owner only e Contractor: Contact Name(s): r Contractor Trade: � ,5 L Mailing Address, C/S/Z: ' o� �. '"��G'TociC--, J 96 Cell EmaPho e: cv,- Z` O c�r.ss'r/'I�� CPJLand Line: � �7 �/� z� "Workers' Comp documentation must be submitted with this application" e En i rs : r Name(s): s ,.. Mailing Addres, C/S/Z:2Lf 'd. !rvT�f�-+ r .Z& d Cell Phone: �L&- Ri 7 —a,` Land Line: Email: /'Vaal /'k_.eeag' r,if,r'--J �5 Contact Person for Compliance in regards to this project: ecc W r"� Cell Phone: Land Line: 1 f G /0 Email: ��: fe< ,C_�Oj-vl 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 Dispo IOrdina PRINT NAME: SIGNATURE: DATE: D"--:n. septic Applicati Revised April 2021 5Eg ©t�31-�z � TOWN OF QUEENSBURY 742 Bay Road, Queensbury, NY. 12804-5902 Septic System Checklist1 FILE COPY� Plan to scale Received Deep hole pert test results from engineer/Architect if applicable(Town Approved Engineers and Architects;June 30 to April 15 Town Engineer for unapproved Engineers and Architects) N All wells on property and adjacent properties shown Mvotc—\Vfl�— water line shown Municipal or well 10'separation to any part of system Setback to property lines show 10'or more for any part of system COI Septic tank and pump stations 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 for0',Separation required (field verification required) Septic tank sized for number of bedrooms and add 250 gals for Jacuzzi tubs/garbage grinder each 1 ,/ W- 1 Leech Field from foundation 100'from any well 10'from water line M p��vL��Qt�O }apt y JF!Seepage pit 150'from well 50'from septic tank Seepage 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 Foundation L0 0 J L0"\ O 13 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 N All tanks anchored or 2' above flood elevation Revised 4/15/2021