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SEP-0742-2021 4 . .......... .:.....: ... :" Office:Cise Onlv:. Permit.M CC` -2oz.t Permit Fee: :>74z Bay Road;Queensbu: 'NY.22804 Pr:5 8-761�8251.7.`W niuv:gueenshurj net �-Z .. .... :.:....;.:........... . a# ....... ... . .....:. Invol ' SEPTIC DISPOSAL'PE.R..MIT'APPLICATION o GV�? Y +rev QeA- ........... Ff :.. . ::.. Pro ect Loc ation 1cl Tax:Ma.p:#: . OCT 07 2021 RESiD:ENCE INFOl. ..6N: Year suil dailoris ' #of be`drQoms: X::gallons per =total daiiy Taira: T�BUILD G COD SRY :... perdaY. ...t bedroom GarbageGrin: er. es; o _ _.. .. _ . 1980.:oc.oldee :15Cl. - .. ...... ...... .. .... .... Installetl '::(circte one}.. ...... 1985-19:91.. 3©: Sa;o:r.Ho `Tub Yes a 1992-Present: :1`1Q Irtstaile ::{eirclesrt } PARCEL_INFORMATCON .......... Topo'graphy.. Flat Rolling.. -Soil'Nature Sand Loam Ctay other,.explain>; Gt�0dwater.:. - :: ,...... ....... ►t;.what:depth :. e.. r'oc.::'.Imperv`ious::materlaf.. :At::nthat.deptti? : ....,:::..::...: .... . _........ D.ornest c water:Su.pply _ iClfunicipaf `i?1/ Ll .. ... : ake. if well or lake;watersupply`from ai1y sept[csystei absorptio.rl:is p :.:.... Perco[atronTest: Rate: er mnt�te: :errncl test:to becam�ptetedb a . . p . ... . ... ........... Itcensed engineer/architect} ... } .. . . .... ...... _. PROPOSED:SI�0 INFORMATION: -= :.. :. . Tank.:;s z bo v gallons min._size 1;000.gallons; add 250;gallo.s for each: arbage:cylin. .er o:r spa/hofi tub l. . ...l /V... ........... .. silem>` :` A Y..: _..: ..:... sprption::field w 12 stone otal 4.e gtYi.. D ft; >FA hi T�rer ti: .:. ... ............. fit,. See a e Pitnr/#3 sfiorte Hoti�v man Pep ; . ;: iFe.:. .................. . erria eve.:ysteiTi. B:ed or.either type: H'alding Tank'SySterr, Total:r :aired ca' it ::: ... . . : . .... . .. ... .... q p Y•. :tan(csaze ....::::::.:. #of tanks- optic Application Revised:December�020. .... ..:.... .............. `::.. :::.GONTAGT .INFORMATI'O:N .PLE-iSE PRINT LEGIBUl OR.TYPE-, PLEASE:fh1CLCl;..AN:EMAIL ............. ... .. ......... ::. :•. A.. ... i nt:: i Narne(s); Mai ling.:Address /Z. _..::. Cell P.:hdneR: 1 Land Line:: _ : ( ) . Pr Mar':Owner s Mailirig:Add;ressl;Cjs/Z �—�GT _ � i" ot .......... ....... CeII:Rhonei n . Lard Li.:`e!: Email: Chec , atl work will be pertrmed by property:owner:onl >: *: :: ontractor:; Contady ame(s) Caritractnr:Trade: Mailing:Address:C ./Z:: . . ... .A. Cell Phone; (:. _ )' ��' t Land.Line: EMa'rI sC_( '�. W©rkers .Clomp..documentat�on:MUS- be Subrn tted::w�th:this application • ri ineer s Name(s)4 .... ........ ... .. . ...... Ma.ilingAddr..ess; C/S/Z: . i { CeN:Phon.e:; .(� �-�— Land_Line.: `l b Email: _. ...... _ _____z r___ Contat(O.erson:for Compliance:in regards.fo thk project: Cell Phone:.::(...::.... .....):.... . . . Land lane: ...(.. ....:. :.� : :...::;..:.. .:..:..:. .: Email; N.OTES';:. :::Alarm system::and associated;:efectricai work:must:�e inspected �y::a:Town::apptaved e eCtr cal .... ... .... .. . ............ inspectitiri>:ag ncy�.2:..We`wili no longer allow:systeriis;.to be::caveretl::until such:time as:an a$ I uilt plan:is .... .......: received:a`d:approved.The installed::systern:must match the::septic::�layout,on:::f te-no;exceptions.5..As ...:::. b:uilt:dravtrings;must;besubmitted:priar':to`:t e.in5pectJanrftherelasbeen'a%c< ngeto:the:siabr»itted .. .. ..: ... PI ans: .:lt::f..or arr.y reason the:;.b.uilding,:perm:it appl:ication.is%Mdthdrawri;3. °%of:tk fed is reCained:bv th Town'of_Queens �ry..A er 1 year from the initial:a` iplicafiioii._date, lOOf of tl?e:#e& s ri�taine-d;. Ca Declaration::An:y.permit Q.r appr..ovai.granted:whicFi:is:based::upon or is granted.in::reliance:upQna:t�.y:materal _.... ......... _: .:. rly representation or failure:to;inake a material fact or.circuinstane knorirn by or.on`beYiaifi_oi aii;applicarit;shall fie: Oold;:! have read the regulations and agree:to abide byl.fiese an.:ail reguirements`.6. the Tbwn of Queer s. U 5anitary5ewage Disposaf ordinar3ce.. c: :'.....::RR[N-::NAME:- . :.A "..dam �'�-(;�::... ..: /�1 :;:. .:.. .: ....::..:.. :: ....:........:.;. ..... :... .. ....:.. ... .. ._.... . . ._.._ . -:..... ..:: .- ...-.... ;:::::::::. I; tGNATURE.... ..... .. ..... .. ......... a.: _.................. .:....:.... ...... ...... :. . .... . SepticA001imidn: Revised:Mcember2020' TOWN OF QUEENSBURY 742 Bay Road, Queensbury, NY. 12804-5902 Septic System Checklist YPlan 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) *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 1Tfrom 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 Seepage pit 150'from well 50'from septic tank A�Neepage Pits 3-times diameter apart Septic tank and pump stations over 30 gallons 50'from watercourse or wetland Zdistance from bottom of trench or system 24"to bedrock or mottling 36"within 1060'of Lake George Leech field 100'from watercourse or wetland YToe of mound or bottom of retaining wall 10'from property line 100'from well 20'from Foundation _�(_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 PAll tanks anchored or 2' above flood elevation Revised 4/15/2021