SEP-0058-2022 SEPTIC DISPOSAL PERMIT office use only
W APPLICATION Permit#: Z)&P—o052) ' 2'022
Town ofQacensbury Permit Fee:$ 8�
Invoice#:
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.aueensbury.net Septic Variance? Y
UN
Flood Zone? Y 6
Wetlands? Y Reviewed By:
Project Location: (s:go.e Rz-)
DECE0V �
Tax Map#: �
FEB 16 2022
RESIDENCE INFORMATION: TOWN OF QUI=ENSBURY
Year Built Gallons #of bedrooms: X gallons per =total daily flow r
per day bedroom Y ge�nn�er es No
1980 or older 150 Installed? (choose one) ❑
1981-1991 130 Spa or Hot Tub Yes
1992-Present 110 Installed? (choose one) ❑
PARCEL INFORMATION:
Topography ] Flat Rolling ❑ Steep Slope % Slope
Soil Nature 2 Sand ❑ Loam ❑ Clay ❑ Other, explain:
Groundwater At what depth? L
Bedrock/Impervious material At what depth?
Domestic Water Supply Municipal ❑Well ❑Lake
Xi
(if well or lake, waterlsupply from any septic system absorption is
Percolation Test Rater per minute per inch (test to be completed by a
licensed engineer/architect)
PROPOSED SYSTEM INFORMATION:
Tank size { o 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 ft.; Each Trench 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
y
Septic Application Revised April 2021
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
Applicant-
Mailing Ad d9f ess, C/S/Z: Ccf [ K Q.,Z
Cell Pho 1�1.7Ci(_^ L5�ot1 Land Line: '
Email:
• Pri a Owners
Name(s):
Mailing.Address, C/S/Z:
Cell Phone: Land Line:
Email:
0 Check if all work.will be performed by property owner only
• ' Contractor:
Contact Name(s):
Contractor Trade:
Mailing Address,.C/S/Z:
Cell Phone: Land Line:
Email:
**Workers'-.Corn p documentation must be submitted with this application**
• Enaineer(s)•
Name(s):
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email:
Contact Person for Compliance in regards to this project: �\CX-Lr
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: NIc/4S
SIGNATURE: DATE:
Septic Application Revised April 2021
TOWN OF QUEENSBURY
742 Bay Road, Queensbury, NY. 12804-5902
Septic System Checklist
!v I n 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)
►J 0 All wells on property and adjacent properties shown
Water line shown Mun I or well 10'separation to any part of system
Setback to property lines show 10'or more for any part of system
CAII
'J, K��eptic tank and_pump stations 10'from foundation 50'from any well/lake/wetland 10'from any waterline
1`NASeptic 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)
7Kiseptic tank sized for number of bedrooms and add 250 gals for Jacuzzi tubs/garbage grinder each
e_/ALeech Field 20'from foundation 100'from any well 10'from water line
M Seepage pit 150'from well 50'from septic tank
NA Seepage Pits 3-times diameter apart
�.S 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
rvlW ' Leech field 100'from watercourse or wetland
oe 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
XA—Department of Health Approval for all mobile home park new systems Flood Plain requirements
/J6 2' above established flood elevation to bottom of system
All tanks anchored or 2' above flood elevation
l? .;cA,4 All si�mi