SEP-0353-2022 SEPTIC DISPOSAL PERMIT Office Use Only
A WAT Permit#
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Town ofOucensbury Permit Fee:$ O y-0
JUN 0 7 2022 Invoice#:
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net TOWN OF QUEENSBURY septic variance? Y .ON
BUILDING&CODES Flood Zone? Y
Wetlands? Y Reviewed By:
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Project Location: Ove-cri-lu�
Tax Map #: 3 a . 1$�a- �S
RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms: X gallons per =total daily flow
per day bedroom ar,•a *ernde.r Yes1980 or older 150 a - 3 os=aD e .. choose one) ❑
1981-1991 130 Yes No
1992-Present 110
Toff-PI TT? (choose one) -a4
PARCEL INFORMATION:
Topography Flat R Iling ❑ Steep Slope % Slope
Soil Nature Sand M Loam ❑ Clay ❑ Other, explain:
Groundwater At what depth?
Bedrock/Impervious material At what depth?
Domestic Water Supply 4D Municipal ❑ Well ❑Lake
(if 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 SYSTEM INFORMATION:
Tank size IMO 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
Septic Application Revised April 2021
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE.AN EMAIL
• Applicant.
• /
Name(s): a K'-I'sz
Mailing Address, C/S/Z: t10 vi,A,'c�,
Cell Phone: $—?1(6— 160'' Land Line:
Email: �ir�s1�11(cx/y�Tco,,,
• PrimaryOwners
Name(s): Obris ur e / J Zgp `1
Mailing,Addre_ss, C/S/Z: 9avec,�56y✓y �14cc �� �t.zchs6✓�"+Y �� T
Cell Phone: s I $' ' 8W'y2 Land Line:
Email:
❑ Check if all work will be performed by property owner only
• Contractor ++// I
Contact Name(s): K od y Kr is+e_'.
Contractor Trade: 41 C.
Mailing Address, C/S/Z: 40 tgVIa1;oo. ood Q� ��N� IZ�o�
Cell Phone: S l a- A6 -f 667 Land Line:
Email:
"Workers" Comp documentation must be submitted with this application"
EnRineer(s):
Name(s):
Mailing Address, C/S/Z:
Cell Phone: -Land-Line:
Email:
Contact Person for Compliance in regards to this project:
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: KodL"
DATE: 6—! V _2 2—
Septic Application Revised April 2021
TOXIN OF QUEENSBURY
742 Bay Road, Queensbury, IVY. 12804-5902
Septic System Checklist
Plan to scale
PAReceived Deep hole pert test results from engineer/Architect if applicable(Town Approved Engineers and
rchitects;June 30 to April 15 Town Engineer for unapproved Engineers and Architects)
N�AII wells on property and adjacent properties shown
Water line shown M--i=--,P—B l 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 10'from foundation 50'from any well/lake/wetland 10'from any waterline
I ,
p✓�1 Septic tank to foundation crawl space/slab on grade,grade in crawl space must be above top of septic tank
/ for0',Separation required (field verification required)
OT-ISeptic tank sized for number of bedrooms and add 250 gals for Jacuzzi tubs/garbage grinder each
n Ll-eech Field 20'from foundation 100'from any well 10'from water line (� r_
I Iln�, j�
1J 6eepage pit 150'from well 50'from septic tank (J
r" /4 Seepage Pits 3-times diameter apart
Septic tank and pump stations over 30 gallons 50'from watercourse or wetland
t✓ distance from bottom of trench or system 24"to bedrock or mottling-3.6"within 1000' of Lake George
„/ /,eQ.eech field 100' from watercourse or wetland
' Toe of mound or bottom of retaining wall 10' from property line 100'from well 20'from
/ Foundation
tAPProvide Engineer/Architect stamp for bed or design systems
4V -Department of Health Approval for all mobile home park new systems Flood Plain requirements
A L 2' above established flood elevation to bottom of system
/1IC11 All tanks anchored or 2' above flood elevation
Revised 4/15/2021
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TOWN OF QUEENSBURY
BUILDING & CODES DEPT,
Reviewed Ys S
Date;
J
Ut4 7T .2
TOWN OF OUEENSBURY �
BUILDING DEPARTMENT MOWN OF QUEENS
D !on our limited examination,compliance 13UILDING$�p��.�
�'Jll(t ow ci:nrn,,iiiS be construed as
indicating the plans and s ecifications are in
full compliance with the uilding Codes of
New York State.
VISED
TOWN OF QUEENSBURY
BUILDING & CODES DEPT.
Reviewed By S
Date: G �`
" X wJL
FILE COP
TOWN OF OUEENSBURY
BUILDING DEPARTMENT _.
Based on our limited examination,compliance a • � �' Y�.�
with our comments shall not be construed as -�
indicating the plans and specifications are.in OW
full compliance with the Building Codes of d
New York State.
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