SEP-0348-2022 1-7
RM9 SEPTIC DISPOSAL PERMIT Office Use Only
APPLICATION Permit#: ai•� • ZA2Z
Town of 0gemsbury.
Permit Fee:$
Invoice#:
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.gueensburV.net Septic Variance? Y N
Flood Zone? Y
Wet] e e e y
Project Location: 5 Glen Court
Tax Map #: 308.5-1-19 JUN 0 3 2022
WN OF QUEENSBURY
RESIDENCE INFORMATION: BUILDING&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) ❑
1981-1991 130 Spa or Hot Tub Yes No
1992-Present 110 4 110 440 Installed? (choose one) ❑
PARCEL INFORMATION:
Topography Q Flat Rolling ❑ Steep Slope % Slope
Soil Nature [1 Sand M Loam ❑ Clay ❑ Other, explain:
Groundwater At what depth? >4'
Bedrock/Impervious material At what depth? >4'
Domestic Water Supply [I Municipal ❑ Well ❑Lake
(if well or lake, water supply from any septic system absorption is
ft.)
Percolation Test Rate: 6-7 per minute per inch (test to be completed by a
licensed engineer/architect)
PROPOSED SYSTEM INFORMATION:
Tank size 1.000 gallons (min. size 1,000 gallons, add 250 gallons for each garbage cylinder or
spa/hot tub (reusing the existing tank)
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'x 40'
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):.Steve Loverinq
Mailing Address, C/S/Z: 5 Glen Court Queenbsurv, NY 12804
Cell Phone{ SIVILP _ Ltr002 Land Line:
Email: Sieve / � �e2nS'l�4- AP—+-
• Primary Owner(s):
Name(s): -Steve Loverinq&Gretchen Luke-Izzo
Mailing Address, C/S/Z: 5 Glen Court Queenbsury, NY 12804
Cell Phone: Q,n ^„ Land Line:
Email:
❑ Check if all work will be performed by property owner only
• Contractor:
Contact Name(s): Fred Smith-Smith's Trucking &Excavating
Contractor Trade: Excavation
Mailing Address, C/S/Z: 23 Vermont Ave Queensburv..NY 12804
Cell Phone: Land Line: 518-798-1836
Email:
"Workers' Comp documentation must be submitted with this application"
• Eneineer(s)•
.Name(s): Hutchins Engineering PLLC
Mailing Address, C/S/Z: 169 Haviland Road Queensbuni, NY 12804
Cell Phone: Land Line: 518-745-0307
Email: thutchins@_hutchinsengineering.com
Contact Person for Compliance in.regards to this project: Tom Hutchins./Steve Loverinq
Cell Phone: Land Line: 518-745-0307
Email: thutchinsCabhutchinsenaineering.com
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: Steve Loverin
(SIGNATURE) DATE: 6/3/22
Septic Application Revised April 2021