SEP-0140-2022 -� SEPTIC DISPOSAL PERMIT office Use Only
APPLICATION Permit#:
Town of(Zccnsbun
Permit Fee:$
Invoice#:
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.gueensbury.net Septic Variance? Y ( N 1
Flood Zone? Y N
tl s —. � 1evtrew d' : _
Project Location: � a.�r �,��� a
MAR 2 8 2022
Tax Map #• ll
TOWN OF OUEENSBURY
RESIDENCE INFORMATION: ING CODES
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) ❑
198171991 130 Spa or Hot Tub Yes No
1992-Present 110 Installed? (choose one) ❑
PARCEL INFORMATION:
Topography lat Rolling ❑ Steep Slope % Slope
Soil Nature Sand ❑ Loam ❑ Clay ❑ Other, explain:
Groundwater At what depth?
Bedrock/Impervious material At what depth?
Domestic Water Supply unicipal ❑ Well" []LakepifweIf well or lake, water supply from any septic system absorption is
ft.)
Percolation Test Rate: per minute per inch (test to be completed by a
licensed engineer/architect)
PROPOSED YSTEM INFORMATION:
Tank size . gallons (min. size 1,000 gallons, add 250 gallons for each garbage cylinder or
pa/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
Septic Application Revised April 2021
f41
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• A IiC t:
-e- 14///.r,
Mailing Address, C/S/Z: 0
Cell Phone: - �?'- D Land Line: ` D
Email: C,7a •iz C,0V—
• PrlmafiOwn ,
Name(s): e '
Mailing Address, C/S/Z:
Cell Phone: Land Line: ei -754= 777�
Email:
❑ Check if all work will be performed by property owner only
• Contractor*
Contact Name(s):
Contractor Trade: c � j
Mailing Address C/S/Z:
Cell Phone. ��-� Land Line:
Email:
"Workers' Comp documentation must be submitted with this application"
• En inee s :
Name(s): kVall
Mailing Address, C S/Z: �� i� ��K�- /-2,
Cell Phone: vta' ' —00 Land Line:
Email:
Contact Person for ompliance in regards to this project:
Cell Phone: Land Lipe:
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 r failure to make a material fact or circumstance known by or on behalf of an applicant, shall be
void. I have read the egulati agree to abide by these and all requirements of the Town of Queensbury
Sanitary Sewage is sal Ordi ce.
PRINT NAME: A f el
SIGNATURE: DATE:zyL�f7
Septic Application Revised April 2021
TOWN OF QUEENSBURY
742 Bay Road, Qteensbury, NY. 12804-5902
Septic System Checklist
WPlan to scale
Received Deep hole perc test results from engineer/Architect if applicable(Town Approved Engineers and
1 rchitects•June 30 to April 15 Town En ine r r n p g e fo unapproved Engineers and Architects)
NO All wells on property and adjacent properties shown
�::C Nater 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
/4ASeptic 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)
�—SSeptic tank sized for number of bedrooms and add 250 gals for Jacuzzi tubs/garbage grinder each
Leech Field from foundation 100'from any well 10'from water line
N L�� Seepage pit 150'from well 50'from septic tank
IJ 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
P�Aeech field 100'from watercourse or wetland
n�Toe of mound or bottom of retaining wall 10' from property.line 100'from well 20' from
Foundation
Provide Engineer/Architect stamp
ILI—
Department of Health Approval for all mobile home park new systems Flood Plain requirements
P/�2' above established flood elevation to bottom of system
nJ6 All tanks anchored or 2' above flood elevation
Revised 4/15/2021
Z
YORKDepartment
ORTUNITY- of Health{.�l
KATHY HOCHUL MARY T.BASSETT,M.D.,M.P.H. KRISTIN M.PROUD
Governor Commissioner Acting Executive Deputy Commissioner
March 18, 2022
E5UC UE vu, RE
Ryan K. Riper, P.E. HAR
RK Engineering, PLLC �0
225 Ruggles Rd Y
Saratoga Springs, NY 12866 TOWNi OF QUEENSBLIRY
SU)LDING o°c CODES
RE: Forest Park Mobile Home Court, Facility 56-6822
Replacement Onsite Wastewater Treatment Systems at Briwood Lot 18 and
Woodland Path Lot 19
Queensbury (T), Warren County
Mr. Riper:
We have this day, approved the plans and specifications for the above-referenced
project. Application for this project was duly made by you on plans titled, "Replacement
Septic System," and was most recently received by this office February 11, 2022. The
project includes installation of replacement onsite wastewater treatment systems to
serve Lot 18 on Briwood Circle and Lot 19 on Woodland Path. The system serving Lot
18 consists of one 1,000-gallon septic tank and ADS Hancor ARC 24 chambers, to
serve one 3-bedroom home. The system serving Lot 19 will consist of the same
components. Approval of these plans is conditioned on the following:
1. That the proposed works be constructed in complete conformity with the
approved plans or amendments thereto;
2. That all components of the proposed works be installed, operated, and
maintained as per the manufacturer's specifications;
3. That approval be granted by other agencies or municipalities have jurisdiction;
4. That the design professional inspects the construction and provides
certification to this office that construction was completed in accordance with the
approved plans. Certification shall also be provided to the Town Office Building
and Code Enforcement.
The responsibility for the design of the sanitary system lies solely with the design
professional and the proper operation of the sanitary system lies solely with the owner.
The purpose of the Department of Health review is for compliance with the New York
State Sanitary Code and in no way guarantees proper system operation. A set of
approved plans is being retained in our files.
Glens Falls District Office,77 Mohican Street.Glens Falls,NY 12801.518-793-38931 gfdo@health.ny.gov
Sincerely,
Brendan O'Connell
Engineer Trainee
NYSDOH — Glens Falls District Office
77 Mohican St.
Glens Falls, NY 12801
(518) 793-3893
cc: Rebecca Bussert, District Director, Glens Falls District Director
Kevin Kenyon, P.E., Glens Falls District Office
Joel Brown, RHP Properties
John O'Brien, Town of Queensbury