SEP-0807-2021 SEPTIC DISPOSAL PERMIT office use only
APPLICATION Permit#: 2>ep-C)bb" - 2-o2)
Town ofQuccnsbury Permit Fee:$ 5
Invoice#:
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.gueensbury.net Septic Variance? Y ( N )
Flood Zone? Y N (�
i� Ll
a�ids?—Y Reviewed By:
Project Location: 21 Hickok Lane i D � U `01
Tax Map #: 227.18-1-20 0 2 2C21
T Inmi nr .. p
' NSUURY
RESIDENCE INFORMATION: . BUILDING&i�5
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
Installed? (choose one) ❑
1992=Present 110 4 110 440
PARCEL INFORMATION:
Topography Flat Rolling ❑ Steep Slope 3-4 % Slope
Soil Nature ❑ Sand Z Loam ❑ Clay W1 Other, explain: Rock
Groundwater At what depth? >6"
Bedrock/Impervious material At what depth? 6"
Domestic Water Supply ❑ Municipal ❑ Well [ILake
(if well or lake, water supply from any septic system absorption is
215 fti)
Percolation Test Rate: per minute per i ch (test to be completed-by a
licensed engineer/architect) ?22 r3x yP�yV&WYW /A'__' F/G4
PROPOSED SYSTEM INFORMATION:
Tank size 1250 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: 15'x4o'Stone Bed
Holding Tank System Total required capacity? ; tank size ;
# of tanks
Septic Application Revised April 2021
+i
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): Edie Perkins Irreovable Trust 2011, Edie Perkins,Trustee
Mailing Address, C/S/Z: 50 Stone Sled Ln Bow, NH 03304
Cell Phone: (603)496-5578 Land Line:
Email: edithperkins@comcast.net
• Primary Owner(s):
Name(s): Same as Applicant
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): Crandall Excavating, Inc.
Contractor Trade: Excavating
Mailing Address, C/S/Z: 63 Woodchuck Hill Rd, Lake George, NY 12845
Cell Phone: (518)470-4694 Land Line: (518)793-0431
i
Email:
"Workers' Comp documentation must be submitted with this application"
Engineer(s)•
Name(s): Hutchins Engineering PLLC
Mailing Address, C/S/Z: 169 Haviland Rd Queensbury. NY 12804
Cell Phone: Land Line: (518)745-03.07 i
Email: LWDobie _hutchinsengineenng.com
f
Contact Person for Compliance in regards to this project: Chris Crandall
Cell Ph o e a.1870--k69q,r.:,-.,. ,.. Land Line: (518)793-0431
Em d"a�
f: .'electrical work must be inspected by a Town approved electrical
e. " low systems to be covered until such time as an as-built plan is
tem must match the septic layout on file—no exceptions. 3. As-
the inspection, if there has been a change to the submitted
`ermit application is withdrawn, 30% of the fee is retained by the!
e initial application date, 100% of the fee is retained. j
itxor approvJgrarited which is based upon or is granted in reliance upon any material
re to make a material fact or circumstance known by or on behalf of an applicant, shall be
e'regulations arid agree to abide by these and all requirements of the Town of Queensbury
�Isposal Ordinance.'
E' Edie Perkins,
,r DATE: 10/27/2021
Revised Ap i
TOWN OF Q UEENSB URY
742 Bay Road, Queensbury, NY. 12804-5902
Septic System Checklist
40 Plan to scale PrOciti& U1PA F,I mow` lS ��S�C ll•(i�
�eceived Deep hole perc test results from engineer/Architect if applicable(Town Approved Engineers and
Architects;June 30 to A ril 15 Town En ineer or unapproved Engineers and Architects)
t All wells on property and adjacent properties shown
IWNater line shown Municipal or well 10'separation to any part of system
4X/�Setback to property lines show 10'or more for any part of system
q-Septic tank and pump stations 10'from foundation 50'from any well/lake/wetland 10'from any waterline
NA—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
44, 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
eech field 100'from watercourse or wetland
y<-'Jroe of mound or bottom of retaining wall 10' from property line 100'from well 20'from
Foundation
�w Provide-Engineer/Architect stamp for bed or design systems
f- �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