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SEP-0684-2022 SEPTIC DISPOSAL PERMIT office use only APPLICATION Permit#:ZeP-T) aeA -2©zL Tcnvn oftti?oensbiny $ I CJ.� Permit Fee: c9 - Invoice#: 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.gueensbury.net Septic Variance No INK Zone? Wetlands? p Reviewed By: Project Location: 3 6� x 4w,,ve Tax Map#: 503 , 1(v - 1- ,Z ©�:1�,-�-`•�- RESIDENCE INFORMATION: Year Built Gallons #of bedrooms: X gallons per =total daily flow per day bedroom Garbage Grinder Yes No 1980 or older 150 '►50 (oci Ilo,,S Installed? (choose one) ❑ ❑ 1981-1991 130 Spa or Hot Tub Yes No 1992-Present 110 Installed? (choose one) ❑ ❑ PARCEL INFORMATION: Topography 9Flat Rolling ❑ Steep Slope % Slope Soil Nature ❑ Sand ❑ Loam ❑ Clay ❑ Other, explain: Groundwater At what depth? Bedrock/Impervious material At hat depth? Domestic Water Supply 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 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 '� Vvt �fr/ r�P _l���r`�c�� v�n © � �t,tinS �„ t all Cv'rjoh�P�' ?� Septic Application Revised July 2022 CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL • Applicant: Name(s): T135 Sep}tc f 9rG:, Mailing Address, C/S/Z: 2. 010 w'f 12�dY Cell Phone: ti'l�-� b'0695,b Land Line: Email: • Primary Owner(s): Name(s): "To r-, i( u v-V-e Mailing Address, C/S/Z: 3 6 S 14Le Cell Phone: 51'%-707-3--�q7 Land Line: Email: ❑ Check if all work will be performed by property owner only • Contractor: Contact Name(s): Contractor Trade: Mailing Address, C/S/Z: Cell Phone: Land Line: Email: **Workers' Comp documentation must be submitted with this application** • Engineer(s)• Name(s): Rt-6-h ki 0451i Mailing Address, C/S/Z: 134 0%x A-eKv P ► ���k� �5��s Cell Phone: S�' `1 `ll-�2(0� Land Line: Email: Contact Person for Compliance in regards to this project: Cell Phone: Land Line: Email: 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: ley SIGNATURE: DATE: ]l t/17--7 z Septic Application Revised July 2022 NEW YORK Department �P - o(ob} - Z°ZZ STATE OF OPPORTUNITY of Health KATHY HOCHUL MARY T.BASSETT,M.D.,M.P.H. KRISTIN M.PROUD Governor Commissioner Acting Executive Deputy Commissioner December 23,2022 D E r E 0 V E Ethan Hall,RA Rusinski Hall Architecture DEC 2 8 2022 134 Dix Avenue Glens Falls,NY 12801 TOWN OF QUEENSBURY Re: Dix Aven ,VgIu ��`CODES Facility Code 56-BD49 Wastewater Treatment System Replacement Dear Mr.Hall, We have this day,approved the plans for the above-referenced project.Application for this project was duly made by you and was most recently received by the New York State Department of Health on December 20,2022. This project includes the replacement-in-kind of the onsite absorption field for the wastewater system. The field consists of a mound with 160-feet of Eljen trenches.The current 1250- gallon septic tank, 1500-gallon grease trap, 500-gallon pump station, and Norweco treatment unit will remain existing.Approval of this project is conditioned on the following: 1. That the proposed works to be constructed in compete 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 having 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; 5. That the dose volume from the pump chamber be determined and adjusted if needed to be within range of dose volume requirements specified by Norweco. The responsibility for the design of the system lies solely with the design professional and the proper operation of the system lies solely with the owner/operator of the system. The purpose of the Department of Health review is for compliance with New York State Sanitary Code and in no way guarantees proper system operation.A set of approved plans is being retained in our files. Sincerely, XIL A6 R.Dan MacElrath Assistant Engineer Glens Falls District Office Cc: Rebecca Bussert,Director GFDO Kevin Kenyon,PE GFDO John O'Brien, Queensbury Code Enforcement Ivan Bell,IBS Empire State Plaza, Corning Tower,Albany,NY 122371 health.ny.gov NEW PORK Department STATE OF OPPORTUNITY. of Health KATHY HOCHUL MARY T.BASSETT,M.D.,M.P.H. KRISTIN M.PROUD Governor Commissioner Acting Executive Deputy Commissioner December 23,2022 Ethan Hall,RA Rusinski Hall Architecture 134 Dix Avenue Glens Falls,NY 12801 Re: Dix Avenue Dunkin Donuts Facility Code 56-BD49 Wastewater Treatment System Replacement Dear Mr. Hall, We have this day,approved the plans for the above-referenced project.Application for this project was duly made by you and was most recently received by the New York State Department of Health on December 20,2022.This project includes the replacement-in-kind of the onsite absorption field for the wastewater system.The field consists of a mound with 160-feet of Eljen trenches.The current 1250- gallon septic tank, 1500-gallon grease trap,500-gallon pump station,and Norweco treatment unit will remain existing.Approval of this project is conditioned on the following: 1. That the proposed works to be constructed in compete 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 having 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; 5. That the dose volume from the pump chamber be determined and adjusted if needed to be within range of dose volume requirements specified by Norweco. The responsibility for the design of the system lies solely with the design professional and the proper operation of the system lies solely with the owner/operator of the system.The purpose of the Department of Health review is for compliance with New York State Sanitary Code and in no way guarantees proper system operation.A set of approved plans is being retained in our files. Sincerely, LA16 R.Dan MacElrath Assistant Engineer Glens Falls District Office Cc: Rebecca Bussert,Director GFDO Kevin Kenyon,PE GFDO John O'Brien,Queensbury Code Enforcement Ivan Bell,IBS Empire State Plaza,Coming Tower,Albany,NY 12237 1 health.ny.gov NEW vORK IDepartment STATE OF OPPORTUNITY. of Health KATHY HOCHUL MARY T.BASSETT,M.D.,M.P.H. KRISTIN M.PROUD Governor Commissloner Acting Executive Deputy Commissioner December 23,2022 Ethan Hall,RA Rusinski Hall Architecture 134 Dix Avenue Glens Falls,NY 12801 Re:Dix Avenue Dunkin Donuts Facility Code 56-BD49 Wastewater Treatment System Replacement Dear Mr.Hall, We have this day,approved the plans for the above-referenced project.Application for this project was duly made by you and was most recently received by the New York State Department of Health on December 20,2022.This project includes the replacement-in-kind of the onsite absorption field for the wastewater system.The field consists of a mound with 160-feet of Eljen trenches.The current 1250- gallon septic tank, 1500-gallon grease trap,500-gallon pump station,and Norweco treatment unit will remain existing.Approval of this project is conditioned on the following: 1. That the proposed works to be constructed in compete 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 having 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; 5. That the dose volume from the pump chamber be determined and adjusted if needed to be within range of dose volume requirements specified by Norweco. The responsibility for the design of the system lies solely with the design professional and the proper operation of the system lies solely with the owner/operator of the system.The purpose of the Department of Health review is for compliance with New York State Sanitary Code and in no way guarantees proper system operation.A set of approved plans is being retained in our files. Sincerely, fp-,r0 6 R.Dan MacElrath Assistant Engineer Glens Falls District Office Cc: Rebecca Bussert,Director GFDO Kevin Kenyon,PE GFDO John O'Brien,Queensbury Code Enforcement Ivan Bell,IBS Empire State Plaza,Coming Tower,Albany,NY 12237 1 health.ny.gov RUCIN.$KI HALL ARCHITECTURE Ronald Richard:Rucinski Ethan Peter.Hall T34 Dix Avenue G . J Glens Falls NY 12801 Voice : 518 741 0268 . Fax . 518 741 0274- ; Email:: ephall@nycap.rr.com :-Dix Ave.Dunkin.Donuts . .. . . 20-January._2023 Town,of.Queerisbury Building Department. 742"Bay Road Queerisbury 'NY.:12804 . Re Installation of Replacement Sewage Disposal System -: At the above.referenced.project location this office..observed.the installation.of the-replacement Eljein bed on 30 December 2022.`The attached draviring'reflects the,current location of the#anks: and fleld:71iis installation is acceptable to this"_ *office'.. If there'.are.any questions;please contact our office to discuss: Regar -Et n:Peter Hall Architect: DEC . JAN.2 0 202 QUci= r�URY NS - �INGG,.� CO. =5 . TOWN UIL. c .