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Application Office Use Only Permit#: c`JEP O b4�+' 2021 Permit fee: $ 742 Say Road.Queensbury,NY 12804 P:51S-761-8256 tgyy gueem ury.net Invoice#:- 2`5 Flood Zone? Y/NfAeviewed SEPTIC DISPOSAL PERMIT APPLICATION Project Location: ecc <ve r lL 5© V`"v` �t ; Tax Map M ZQi 5 lg 2 -?Yta RESIDENCE INFORMATION: Year Built Gallons If of bedrooms: X gallons per -total daffy flow �_ per day bedroom 5 Garbage Grinder Yes 1980 or older 150 I Installed? (circle one) 1I 1981-1991 130 Spa or Hot Tub Yes i ll t Insaed? (circle one) 1992-Present Ili � i�C) _ _ PARCEL INFORMATION: Topography Flat Rolling Steep Slope _% Slope _ -- Soil Nature Sand _ Loam _ Clay _Other, explain: Groundwater At w at depth? Bedrock/Impervious material At hat depth? Domestic Water Supply _ Municipal _Well _ Lake I (if well or lake, water supply from any septic system absorption is ft.) _ Percolation Test t Rate: I per minute per inch (test to be completed by a licensed engineer/architect) PROPOSED SYSTEM INFORMATION: Q-W _ P zi:,& 2A Tank size I: gallons (min. size 1,000 gallons, add 250 gallons for each garbage cylinder or e�5t'1 spa/hottub ' System Absorption field w/#2 stone i Total length ft.; Each Trench Seepage Pit w/#3 stone How many. ; Size: Alternative System Bed or other type: ( - I Holding Tank System Total required capacity? ; tank size 2y Al of tanks ?•�" Septic Application Revised December 2020 CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL • A licant: Name(sl:_ 7 Mailing Address, C/S/Z: r W(a-y- �k,( QFL u Cell Phone: _( ) Land Line: _( j Email: • Primary Owner(s): Name(s): Mailing Address, C/S/Z: - Cell Phone:_( ) Land Line: _(��IR j �C CI(.,77 Email: Com ❑ Check if all work will be performed by property owner only • Contractor: Contact Name(s): 'F�4PRhG� f to Contractor Trade: ' —'G Mailing Address, C S/Z: 1_f�)t_A_f r l ate' a cn's+ Cell Phone: _( j �i0 ( - oZ U to 5 Land Line: Email: �� CICWt\h�\kf� DT I cC�sn�) **Workers' Camp documentation must be submitted with this application" • EnAineer(s): Name(s): Mailing Address, C/S/Z: Cell Phone: _( } Land Line: _( j Email: Contact Person for Compliance in regards to this project: Cell Phone:. I Land Line: I Email: —_— 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. (1 PRINT NAME: SIGNATURE: DATE: 1 Septic Application Revised December 2020 CLTOWN OF QUEENSBURY 742 Bay Road, Queensbury, NY. 1 2 8 04-5 902 Septic System Checklist -ALPlan 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) tJ All wells on property and adjacent properties shown �( 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 Septic tank and pump stations 10'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 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 IJ�Seepage pit 150'from well 50'from septic tank Seepage Pits 3-times diameter apart Septic tank and pump stations over 30 gallons 50'ffrom watercourse or wetland distance from bottom of trench or systeZjjwKeclrock 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 Lp P iE- \ �,P—N,-�IE 12S ,l 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 All tanks anchored or 2' above flood elevation Revised 4/15/2021 N� 0El m I]3 W L z D ECEU 1J y DQ SEP 19 2021 (a o > TOWN OF QUEENSBURY C � BUILDING 8 CODES G Hrc z 0 M. =BUILT L \ t y ,�/7 r � J i 0 3 s � . 0 3 tr N 4 N U C o� Z W Oi J Ip$ �"Al NO "-fO NU .t � .Q yw Quick4 The Quick4® Equalizer 24 Chamber INFILTRATOR water technologies Quick4'Series h The Quick4®Equalizer 24 Chamber fits in a 18" wide trench ^. , and is ideal for curved or straight systems. It features the �Y patent-pending Contour Swivel Connection- which permits turns up to 100, right or left. The MultiPort•° endcap allows multiple piping options and eliminates pipe fittings. The chamber's four-foot length provides optimal installation flexibility. Chamber Benefits: •Advanced contouring connections swivel up to 100, right or left k r; • Reinforced ribs provide increased structural capability ' 'N and durability • Compact nesting provides more trench length in an equivalent stack height • Four-foot chambers are easy to handle and install • The Quick4 Equalizer 24 Chamber supports wheel loads of 16,000 Ibs/axle with only 12"of cover • Certified by the International Association of Plumbing and Mechanical Officials(IAPMO) C � u MultiPort Endcap Benefits: ; •Tear-out seals on inlet ports provide a tight fit to the pipe • Six molded-in inlets/outlets allow QuickC Series for maximum piping flexibility Because installations are faster with Quick4 • Fits on either end of the Quick4 Equalizer 24 Chamber chambers, APPROVED in operation labor. Quic_k_4 Quick4 Equalizer 24 Chamber n„ l 48" 18„ EFFECTIVE LENGTH MultiPort EndCap 1 12„ 14„ ! AllI E FRONT VIEW SIDE VIEW TOP VIEW INFILTRATOR WATER TECHNOLOGIES STANDARD LIMITED WARRANTY Typical Trench View (a)The structural integrity of each chamber,endcap and other accessory manufactured by Infiltrator("Units"),when installed and operated in a leachfield of an onsite septic system in accordance with Infiltrator's instructions,is warranted to the original purchaser("Holder against NATIVE BAGKFILL TOPSOIL defective materials and workmanship for one year from the date that the septic permit is issued for the septic system containing the Units;provided,however,that if a septic permit is not required by applicable law,the warranty period will begin upon the date that installation of the septic system commences.To exercise its warren rights,Holder must notify Infiltrator in writing at its le 2 ^%>:%a�_�.;t warrantyty 9 Corpora ��•'S..c:�:, ,,.�:. II� COVER BY �,;.:.: .,,:�:;II- Headquarters in Old Saybrook,Connecticut within fifteen(15)days of the alleged clefect Infiltrator `• 'a:="�;�' Ih DESIGN ; �y T,111 will supply replacement Units for Units determined by Infiltrator to be covered by this Umited Warranty.Infiltrator's liability specifically excludes the cost of removal and/or 11" `._� 11' ,•�, installation of the Units. + 7.,' 1 Y-;' `•? 6"INVERT (b)THE LIMITED WARRANTY AND REMEDIES IN SUBPARAGRAPH(a)ARE EXCLUSIVE. THERE ARE NO OTHER WARRANTIES WITH RESPECT TO THE UNITS,INCLUDING NO 16' PACING PER CODE 16" IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE I-� S --{ (Ie-wloE (c)This Limited Wertanty,shall be void l any part of the chamber system is manufactured by TRENCH) anyone other than Infiltrator. The UmBed Warrant does not extend to incidental,con sequential, sequential, special or indirect damages.Infiltrator shall not be liable for penalties or liquidated damages, F Equalizer Chamber Specifications r including loss of production and profits,labor and materials,overhead costs,or other losses or expenses incurred by the Holder or any third party. Specifically excluded from Limited Warranty Size 16"W X 53"L X 11"H covemge are damage to the Units due to ordinary wear and tear,alteration,accident misuse, abuse or neglect of the Units;the Units being subjected to vehicle traffic or other conditions which (406 mm x 1346 mm x 279 ram) are not permitted by the installation instructions;failure to maintain the minimum ground covers set forth in the installation instructions;the placement of improper materials into the system Effective Length 48" (1219 ram) containing the Units;failure of the Units or the septic system due to improper siting or improper sizing,excessive water usage,improper grease disposal,or improper operation;or any other Louver Height 9.10" (231 ram) event not caused by Infiltrator. This Linked Warranty shall be void if the Holder falls to comply with all of the terms set forth in this Limited Warranty.Further,in no event shall Infiltrator be Storage Capacity 21 gal (79 L) responsible for any loss or damage to the Holder,the Units,or any third party resulting from installation or shipment,or from any product liability claims of Holder or any third party.For this Invert Height 6" (152 ram) Limited Warranty to apply,the Units must be installed in accordance with all site conditions required by state and beat codes;all other applicable laws;and Infiltrator's Installation instructions. (d)No representative of Infiltrator has the authority to change or extend this Umhed Warranty. No warranty applies to any party other than the original Holder. The above represents the Standard Limited Warranty offered by Infiltrator. A limited number of 4 Business Park Road stales and counties have different warranty requirements. Any purchaser of Units should contact P.O.Box 76% Infilbator's Corporate Headquarters in Old Saybrook,Connecticut,prior to such purchase,to Oki Saybrook.CT 06475 860-577-700D•Fax 860-577-7001 obtain a copy of the applicable warranty,and should carefuly read that warranty prior to the INFILTRATOR 1.600.221.4436 purchase of Units. water technologies www.infiltretorwatercom U.S.Patents:4,759.661;5.017,041;5,156.488;5.336,017;5.401,116;5,401,459;5,511,90$5,7t6.163;5.588,778;5.839.844 Canadian Patents 1,329,959:2,004,564 Omer patents pending. Infihrtor,Equalax.Quick4,and SideWUMer are registered trademarks of Infihrator Water Tedmolugies.Inf ftmem is a registered trademark in fiance.Infiltrator WatwTechrwbgies is a registered trademark in Mexico. Contour,MicroLeaching,PolyTuB,CharnberSPaoer,MuktPort,Posil-ock,ou6,CuL Ouidd%y.Snapl-ockand StraightLoek are trademarks of InRtratx Water Technologies. Polyl-ok is a trademark of P*Lok,Inc.TUF-TITS is a registered trademark of TUF-TTTE,INC.Uhre-Rib is a trademark of IPEK Inc. 02013 Infiltrator Water Technologies,L.C.All rights reserved.Printed in U-SA 0180713 11115• • • • • - - • , • :11