SEP-0784-2021 r
SEPTIC DISPOSAL PERMIT Office Use Only
APPLICATION Permit#: ZQZI
Town ofQueensbury
Permit Fee:$
Invoice#:
742 Bay Road,Queerisbury,NY 12804
P:528-761-8256 www.auednsbury.net Septic Variance? Y 'ON
)
Flood Zone? Y
Wetlands? Y Reviewed B .
Project Location: 2283 Ridge Rd.
Tax Map #: 240 1-5
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) ❑
1981-1991 130 Spa or Hot Tub Yes No
1992-Present 110 3 110 330 Installed? (choose one) ❑
PARCEL INFORMATION:
Topography ® Flat Rolling ❑ Steep Slope % Slope
Soil Nature N_Sand N Loam ❑ Clay ❑.Other, explain:.
Groundwater At what depth? 60"+'
Bedrock/Impervious material At what depth? N/A
Domestic Water Supply ❑ Municipal KZ Well ❑Lake
(if well or lake, water supply from any septic system absorption is
Percolation Test Rate: 3.5 per minute per inch (test to be completed by a
licensed engineer/architect)
PROPOSED SYSTEM INFORMATION:
Tank size 1000 gallons (min. size 1,000 gallons, add 250.gallons for each garbage cylinder or
spa/hot tub
System Absorption field w/#2 stone Total length 138 ft.; Each Trench 46 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): Melissa Klebes
Mailing Address, C/S/Z: 2283 Ridge Rd., QU 12804
Cell Phone: 518-222-3010 Land Line:
Email: melissafrench760@yahoo.com
• Primary Owner(s):
Name(s):
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email:
❑ Check if all work will be performed by property owner only
• Contractor:
Contact Name(s): FIG Dickinson Construction
Contractor Trade: GC
Mailing Address, C/S/Z: 818 Tryesdale Hill Rd. LG 12845
Cell Phone: 518-321-5315 Land Line:
Email: h.garthdi@hotmail.com
**Workers' Comp documentation must be submitted with this application**
• Engineer(s)•
Name(s): DL Dickinson Associates.
Mailing Address, C/S/Z: PO Box 388, Lake George, NY 12845
Cell Phone: 518-339-7451 Land Line:
Email: didickinson78@gmail.com
Contact Person for Compliance in regards to this project: Garth Dickinson
Cell Phone: 518-321-5315 Land Line:
Email: h.garthdi@hotmail.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: Melissa Klebes
SIGNATURE: DATE: 10-20-21
Septic Application Revised April 2021
TOWN OF QUEENSBURY
742 Bay Road, Queenshury, NY. 12804-5902.
Septic System Checklist
�*Ian to scale
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)
XAll 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
Xseptic 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
ALeech Field 20'from foundation 100'. from any well 10'from waterline
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
A— dist'ance' from bottom of trench or system 24"to bedrock or mottling 36"within 1000'of Lake George
A-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
Y&ovid En e'er Architec tam for bed or design systems 5,yr�\/L57,q? ,
Department of Health Approval for all mobile home park new systems Flood Plain.requirements
2' above established flood elevation to bottom of system
t�V All tanks anchored or 2' above flood elevation
Revised 4/15/2021