SEP-0767-2021 SEPTIC DISPOSAL PERMIT Office Use Only
APPLICATION Permit#:
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Permit Fee:$tcab
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742 Bay Road,Queensbury,NY 12804 E l� '`�
P:518-761-8256 Www.aueensbury.net D ;WePtCJsrJ
is�c �Reviewed By:
TOWN pB QU NSBURY
Project Location: 16 TERRACE RO D BUILDING—& Cpp`S
Tax Map #: 297.10-1-27
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) ❑ EZ
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: SILT
Groundwater At what depth? 34"
Bedrock/Impervious material At what depth? >44"
Domestic Water Supply ❑ Municipal V Well ❑Lake
(if well or lake, water supply from any septic system absorption is
102 ft.)
Percolation Test Rate: 14:00 per minute per inch (test to be completed by a
licensed engineer/architect)
PROPOSED SYSTEM INFORMATION:
Tank size gallons (min. size 1,000 gallons, add 250 gallons for each garbage cylinder or
spa/hot tub EXISTING TANK TO BE INSPECTED AND REUSED
System Absorption field w/#2 stone Total length 275 ft.; Each Trench 55 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): Abert Gilet
Mailing Address, C/S/Z: 16 Terrace Drive, Queensbury. NY
Cell Phone: 515,744.2633 Land Line: 518.798.1345
Email: albert.gilet@gmail.com
• Primary Owner(s):
Name(s): Gilet Farnily Irrevocable Trust
Mailing Address, C/S/Z: 16 Terrace Drive, Queensbury. NY
Cell Phone: 515.744.2633 Land Line: 518.798.1345
Email: albert.gilet(a)g mail.com
❑ Check if all work will be performed by property owner only
• Contractor:
Contact Name(s): Jon Sweet Construction
Contractor Trade: Installation
Mailing Address, C/S/Z: 290 Palmer Rldae Road. 12831
Cell Phone: 518.791.1285 Land Line:
Email: jsweet1961@yahoo.com
**Workers' Comp documentation must be submitted with this application**
• Engineer(s):
Name(s): HUTCHINS ENGINEERING
Mailing Address, C/S/Z: 169 HAVI LAND ROAD, QUEENSBURY, NY 12804
Cell Phone: Land Line: (518) 745-0307
Email: THUTCHINS@HUTCHINSENGINEERING.COM
Contact Person for Compliance in regards to this project: ENGINEER-SEE ABOVE .
Cell Phone: Land Line:
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.
PRINT NAME: fhNf7' ro
SIGNATURE: -VI DATE: 17-1
ly
Septic Application Revised April 2021
TOWN OF QUEENSBURY
742 Bay Road, Queensbury, NY. 12804-5902
Septic System Checklist
NO Plan to scale
eceived 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)
ffKAll wells on property and adjacent properties shown
Idwater line shown Municipal or well 10'separation to any part of system
L
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
HJA 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 eachx� N(•►
Leech Field Field 20'from foundation 100'from any well 10'from water. line
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 system 24"to bedrock or mottling 36"within 1000' of Lake George
C6ech field 100'from watercourse or wetland
Aloe of mound.or bottom of retaining wall 10'from property line 100'from well 20'from
Foundation
7JQProvide 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
NV All tanks anchored or 2' above flood elevation
Revised 4/15/2021