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SEP-0080-2023 SEPTIC DISPOSAL PERMIT office Use only APPLICATION Permit#: Town of Qucensbory -.,,�,�� ()v Permit Fee:$ D E C E Invoice#: 742 Bay Road,Queensbury,NY 128 � � y p P:518-761-8256 www. ueensbu . ! 1 21Q231 Septic Variance? Y 1� N TOWN OF QUEE(V8C3URY Flood Zone? Yaeviewed BUILDING& CO Wetlands? Y Ev Project Location: Co,-nor On Cf Tax Map #: � RESIDENCE INFORMATION: Year Built Gallons #of bedrooms: X gallons per =total daily flow per day bedroom Garbage Grinder Yes No 1980 or older 150 i 1 D IS,: Installed? (choose one) ❑ g 1981-1991 130 Spa or Hot Tub Yes No 1992-Present 110 Installed? (choose one) ❑ PARCEL INFORMATION: Topography lat Rolling ❑ Steep Slope % Slope Soil Nature XSand Loam ❑ Clay ❑ Other, explain: Groundwater At what depth? Bedrock/Impervious material At what depth? N a' 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) on d r-a- z. t PROPOSED SYSTEM INFORMATION: Tank size A90 0 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 &0 ft.; Each Trench JILQ 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 July 2022 r CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL • Applicant• Name(s): nrQAA_,,,, Mailing Address, C/S/Z: e, SSO &lam ., ►- Cell Phone: �) 44 7 i 6 ��� Land Line: PJ1q -1 a- Sqa Email: )--Nc,,,)c,—.-,- "na—,, <-J, C►1 • Primar caner s :��� Name(s): j /1 /� Mailing Address, C/S/Z. D t ��� A `J l�1-f Cell Phone: - /v'�-/�C.�S Land L e Email: e. Alo , eom ❑ Check if all work will be performed by property owner only • Contractor: l Contact Name(s): ► 5► 1Ack.)e jS Contractor Trade: G Cwv Mailing Address, C/S/Z:O'\6 Cell Phone: S1 `14 1111 Land Line: 5'� 1 �►� S��I Email: A.uQa (0 \I Lt � **Workers' Comp documentation must be submitted with this application** • En ineer s : Mailing Address, C/S/Z: I.NA Cell Phone: Land Line: Email: Contact Person for Compliance in regards to this project: c 1 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: SIGNATURE: DATE: Septic Application Revised July 2022 TO OF QUEENSBURY M Bay Road, Queensbury, IVY. 12804-5902 Septic System Checklist )-�P—Plan to scale Received Deep hole perc test results from engineer/Architect if applicable(Town Approved Engineers and Architects;June 30 to April 15 Town Engineer for unapproved Engineers and Architects) tAll wells on property and adjacent properties shown -Waterline shown Municipal 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 L�--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) Septic tank sized for number of bedrooms and add 250 gals for Jacuzzi tubs/garbage grinder each �t—Leech Field 20'from foundation 100'from any well 10' from waterline "y -eepage pit 150'from well 50'from septic tank YIA-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. Leech field 100'from watercourse or wetland Toe of mound or bottom of retaining wall 10'from property line 100'from well ZO'from Foundation Provide Engineer/Architect stamp for bed or design systems )lhepartment of Health Approval for all mobile home park new systems Flood Plain requirements 1Z2'above established flood elevation to bottom of system I"V All tanks anchored or 2' above flood elevation RUCINSK HALL ARCHITECTURE Ronald Richard Rucinski Ethan Peter Hall 134 Dix Avenue s ����� Glens Falls NY 12801 Voice 518 741 0268 Fax 518 741'0274 Email ephall@nycap.nr.com __� _•a-� Wade Residence- 3 Country Colony:Road . 13.March 2023: w . Town of Queensbury Building Department: r�}�i�l GFY U1Li1r<G �GGC�ES 142 Bay Road Queehsbury 'NY: 12804 ©0 Re: Installation of Replacement Sewage Disposal System At the�above referenced project location this office.obse.rved'the installation of the new,gravity lateral system and-distribution box. Following inspection of the:ezisting tank; a new- 1.,000 gallon_ tank was installed as mentioned before construction: The tank meets all'well separations.and building%pro.perty line minimums. A Zabel effluent filter was-also installed to,the new tank..This installation.is,-acceptable to this office:.If there are-any questions please contact:our office to discuss. Regar E n Peter Architect