SEP-0298-2022 SEPTIC DISPOSAL PERMIT Office use Only
APPLICATION Permit#: 5C—R e2�j8- 2�Z2
Town of ueens6
"'y Permit Fee:$ 85�
Invoice#: -ACA b
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 vuww.oue2nsbury.net FI ? Y Reviewe
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Project Location: 21 RAPPAPORT DR MAY 182022
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Tax Map#: 239.12-2-76 T U k pr QUEF�
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RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms: X gallons per =total daily flow
per day bedroom Yes N
1980 or older 150 &w (choose.one)
1981-1991 130 Spa or Hot Tub Yes
1992-Present 110 3 110 330 1Installed? (choose one)
PARCEL INFORMATION:
Topography Flat Rolling Steep Slope % Slope
Soil Nature Sand Loam Clay Other, explain:
Groundwater At what depth? GREATER THAN 6 FT
Bedrock/Impervious material At what depth? 64"
Domestic Water Supply Municipal Well Lake
(if well or lake, water supply from any septic system absorption is
ft.)
Percolation Test Rate: 7.5 per minute per inch (test to be completed by a
licensed engineer/architect)
PROPOSED SYSTEM INFORMATION:
Tank size l000 gallons (min. size 1,000 gallons, add 250 gallons for each garbage cylinder or
spa/hot tub NEW 1000 GAL CONCRETE
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:20 FT X 40 FT
Holding Tank System. Total required capacity? ; tank size. ;
# of tanks
Septic Application Revised January 2021
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): MIKE GRASSO
Mailing Address, C/S/Z: 23 RAPPAPORT DR QUEENSBURY,NY 12804
Cell Phone: Land Line: 518 365 6303
Email:
• Primary Owner(s)::
Name(s): SAME AS APPLICANT
Mailing Address, C/S/Z: r!"j
Cell Phone: 'Lan'd Line:
Email:
Check if all work will be performed by property owner only
• Contractor:
Contact Name(s):DAVID HOWARD
Contractor Trade: HOWARD EXCAVATING
Mailing Address, C/S/Z:LUZERNE RD, QUEENSBURY, NY 12804
Cell Phone: Land Line:518-361-0714
Email:HOWARD35_2000@YAHOO.COM
"Workers' Comp documentation must be submitted with this application"
• Enpineer(s):
Name(s): HUTCHINS ENGINEERING, PLLC-TOM CENTER
Mailing Ad.dress, C/S/Z:169 HAVILAND ROAD, QUEENSBURY,NY 12804
Cell Phone: Land Line: 518-796-2515
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 regul ' s and.ag a to abide by these and all requirements of the Town.of Queensbury
Sanitary Sewage D' sal Ordinance.
PRINT NAME: AVID HOWARD
SIGNATURE: DATE:
a �? ?0-
Septic Application Revised January 2021
I
TOWN OF QUEENSBURA'
742 Bay Road, Queensbury, NY. 12804-5902
Septic System Checklist
Plan to scale
`< Received Deep hole pert test results from engineer/Architect if applicable(Town Approved Engineers and
Architects;June 30 to April 15 Town Engineer for unapproved Engineers and Architects).
YAll wells on property and adjacent properties shown
Ywater line shown Municipal or well 10'separation to any part of system
YSetback 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
—)(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)
YC
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 waterline
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,
�i
�.Leech
distanc from bottom of trench or system 24"to bedrock or mottling 36"within 1000' of Lake George
field 100'from watercourse or wetland
Yroe 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
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