Loading...
SEP-0820-2021 SEPTIC DISPOSAL PERMIT office Use only j APPLICATION Permit#: �P-062D -?�Ll Town of Qucen Gas ry Permit Fee:$ Invoice#: '1��✓ 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.4ueensburv.net Flood Zone? Y O Reviewed By: Project Location: 54 WESTERN AVENUE Tax Map #: 302.191-30TOKp� OF _ RESIDENCE INFORMATION: -. 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) X 1981-1991 130 Spa or Hot Tub Yes No 1992-Present 110 2 (EX) + 1(F) =3 110 330 Installed? (choose one) X PARCEL INFORMATION: Topography ✓ Flat Rolling Steep Slope % Slope Soil Nature VSand Loam Clay Other, explain: Groundwater At what depth? GREATER THAN 6 FT Bedrock/Impervious material At what depth? GREATER THAN 6 FT Domestic Water Supply Municipal Well Lake (if well or lake, water supply from any septic system absorption is ft.) Percolation Test Rate: 1-5MIN 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 EX: 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:15 FT X 25 FT Holding Tank System Total required capacity? ; tank size ; # of tanks Septic Application Revised Janua CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL • Applicant: Name(s): ROGER LANGWORTHY Mailing Address, C/S/Z: 54 WESTERN AVENUE. QUEENSBURY,NY 12804 Cell Phone: Land Line: Email: • Primary Owner(s): Name(s): SAME AS APPLICANT Mailing Address, C/S/Z: Cell Phone: Land Line: Email: Check if all work will be performed by property owner only • Contractor: Contact Name(s):SANITARY SEWER SERVICES Contractor Trade: Mailing Address, C/S/Z:LUZERNE RD, QUEENSBURY Cell Phone: Land Line:518-796-3760 Email: "Workers' Comp documentation must be submitted with this application" • Engineer(s): Name(s): CENTER PROJECT SERVICES Mailing Address, C/S/Z:73 SHERIDAN STREET, GLENS FALLS NY 12801 Cell Phone: Land Line: Email: Contact Person for Compliance in regards to this project: GEORGE DRELLOS Cell Phone: Land Line: 518-796-3760 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 agr abide by these and all requirements of the Town of Queensbury Sanitary Sewage Disposal Ordinance PRINT NAME:GEORGE DRELLOS SIGNATURE: DATE: Septic Application Ra,,;�o� i,,,,,,")ml TOWN OF QUEENSBURY 742 Bay Road, Queensbury, NY. 12804-5902 Septic System Checklist �.S 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) -�AII wells on property and adjacent properties shown ' -Water line shown Municipal or well 10'separation to any part of system �'Q,-S Setback to property lines show 10' or more for any part of system �tLJ—Septic tank and pump stations 10'from foundation 50'from any well/lake/wetland 10'from any waterline N*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) Z�jSeptic tank sized for number of bedrooms and add 250 gals for Jacuzzi tubs/garbage grinder each I-t�5 Leech Field 20'from foundation 100'-from any well 10'from water line rf�Seepage pit 150'from well 50'from septic tank Seepage Pits 3-times diameter apart CJY,d 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 �j Leech field 100'.from watercourse or wetland e aining wa 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 r.J 0 2' above established flood elevation to bottom of system /,J 6 All tanks anchored or 2' above flood elevation rig. � Revised 4/15/2021