Application r
SEPTIC DISPOSAL PERMIT office use only
A - Permit#:I
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Permit Fee:�$
JUN 07 2021 .J i Invoice 'B
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.gueensbury.net TOWNS Ft-,Iz,-, Septic Variance? Y
OF U_ n30JRY
BJfLDIPdU Flood Zone? YRN
f�
Wetlands? Y Reviewed By:
Project Location: 11 144dr-JEFoR6 1046
1v ore
Tax Map #: 1 No, ` - I- zn pAfvroudLy iyIPA��fo RFpU1cFi,pr 46reAenou aEo.
tEPnc %�►+��t,yaJ� pua►inowC/{ rGJrn
RESIDENCE INFORMATION: ul r►aa OF euEC.rtlfkdy pRvpEnry
Year Built Gallons #of bedrooms: X gallons per =total daily flow r FE'L 4�✓r
per day bedroom Garbage Grinder Yes No
1980 or older 150 Installed? (choose one) ❑
1981-1991 130 Spa or Hot Tub Yes No
1992-Present 110 3 110 33o Installed? (choose one) ❑
El
me%'1 lC %JCS(/t2 Z ! Q� Q" Qf
PARCEL INFORMATION:
Topography ® Flat Rolling ❑ Steep Slope Z % Slope
Soil Nature f Sand [ Loam ❑ Clay ❑ Other, explain:
C't 4 v&r Ai.+o c-o
Groundwater At what depth? u 4 - ^00^.tc fr ydo
Bedrock/Impervious material At what depth? yoia
Domestic Water Supply ❑ Municipal V,] Well ❑Lake
(if well or lake, water supply from any septic system absorption is
103.g ft.)
Percolation Test Rate: 3,0 per minute per inch (test to be completed by a
licensed engineer/architect)
PROPOSED SYSTEM INFORMATION:
Tank size 4000 gallons (min. size 1,000 gallons, add 250 gallons for each garbage cylinder or
spa/hot tub laao C.
System Absorption field w/#2 stone Total length ft.; Each Trench ft.
Seepage Pit w/#3 stone How many: : Size: j
Alternative System Bed or other type: 1d Yo s e
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): j or�t Ct"O S
Mailing Address, C/S/Z: 37,? fhA)yV,aW C (ajct �0 �� /2 P {q1
Cell Phone: 9I`Y- 7/5-,?f00 Land Line: Alo v+e-
Email: M4R0ySd (P42VA;/. r�L
• Primar Owner(s)
Name(s): a o z- /ly CLP-0aS
Mailing Address, C/S/Z: (a 0 (,b 04.c-
Cell Phone: 011(1-W -7 40 Land Line: d1B�1�
Email:-/�✓K OSc3 (e q/yJpil L'D/pf
❑ Check if all work will be performed by property owner only
• Contractor:,� //
Contact Name(s): /Nr Ok-ca
Contractor Trade: V a �jJ/ p �/�oL�A� NY lZb'Z7
Mailing Addressd C/S/Z: (o �(L A(i/� �2t�t� /I�,
Cell Phone: SV- 796 -/W Land Line: 79R-.�867�
Email: l/Q i!/ Vd-ADoe co/Z
**Workers' Comp docu�entation must be submitted with this application"
• En¢ineer(s): W-e w/-/la P-02 .J2a"&Z 7 6
Name(s): 904- w/acwf/' ToD4 ov, DtleeifshatRy
Mailing Address, C/S/Z: Ao• BoK 1I6, (AeJrC-Ag a, nay fzP 7
Cell Phone: ULf Land Line: (s-Q) Yfy-RSSf
Email: buinc��pFw%ocfi;�u�{weer%�,cu.y
Contact Person for Co m fiapnce in regards to this project: / ,4 K
Cell Phone: Q/V-7/-0 PV Land Line:
Email: -16M�gOdS�GLe j CIp j
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 Dise
PRINT NAME:�� osal Ordinance.
SIGNATURE: DATE:E�/ �/ L/
Septic ApplicaYwn '"]�T� Revised April 2021
TOWN OF QUEENSBURY
742 Bay Road, Queensbury, NY. 12804-5902
Septic System Checklist
Plan to scale
,J�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)
D!A ox t'rA Ce of c �c r a.ti & pu v' Q +a r\.
II wells on prope y and adjacent properties shown
�aater line shown Municipal or well 10'separation to any part of system
I?ISSetback to property lines show 10' or more for any part of system
17[,S_Septic tank and pump stations 10'from foundation 50'from any well/lake/wetland 10' from any waterline
JVLSeptic 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)
�r-S septic tank sized for number of bedrooms and add 250 gals for Jacuzzi tubs/garbage grinder each
rJA-Leech Field 20'from foundation 100' from any well 10'from waterline
w�A Seepage pit 150'from well 50' from septic tank U
�A--Seepage Pits 3-times diameter apart
l Septic tank and pump stations over 30 gallons 50' from watercourse or wetland
N_distance from bottom of trench or system 24"to bedrock or mottling 36"within 1000'of Lake George
r✓ Leech field 100'from watercourse or wetland
,,J*Toe of mound or bottom of retaining wall 10'from property line 100'from well 20'from
Foundation
t!S Provide Engineer/Architect stamp for bed or design systems
III�'��Department of Health Approval for all mobile home park new systems Flood Plain requirements
I
' b 2' above established flood elevation to bottom of system
lJ a All tanks anchored or 2'above flood elevation
�f i n �, .F 1-�1 zzs►-�/
Regarding:
11 Hanneford Rd
Queensbury, NY 12845
Greetings:
Attached is my application for a Septic Disposal Permit. This is not for a new system it is to
upgrade the existing system that was discovered to be out of compliance during a Property
transfer Inspection 6/13/2019 ( 1 have attached a copy of the inspection Worksheet)
Also as a FYI I upgraded the waster Water Disposal Bed ( mound system) in 2015 and attached
a copy of the Certificate of Compliance
The current project is to upgrade the existing 500 gallon tank to a !000 gallon size, I had held
off doing so due to the complexity and expense of the project but am ready now- the
topography (ledge rock and tight quarters led my engineer to the best solution possible he
could determine.)
Just a FYI- I do have a buyer and am committed to completing before the sale
Please contact me with questions , concerns etc..
Thanks
Tom Groos
914-715-8800
tomgroos2@amail.com
Residence Address:
58 Christiana Ct. » -_N-� fl
Lake George, NY 12845 "
I JUN 0 7 2021
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OWN OF QUEENSBURY
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