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SEP-0203-2023 SEPTIC DISPOSAL PERMIT office use Only APPLICATION Permit#: Town ofQac n b ry Permit Fee:$ �5 Invoice#: 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.gueensbury.net Septic Variance? Y O Flood Zone? Y G Wetlands? Y (l Reviewed By: Project Location: I ( y ---3rp, Tax Map #: �� • � — � — �� � � _ �-----�K,�n.�.�� MAY RESIDENCE INFORMATION: F ,��I E��F,F;U'R TOWCCZ Year Built Gallons #of bedrooms: X gallons per =total daily flow IL�J4i'RO _�,0D,-'- BU per day bedroom Garbage Grinder Yes No 1980 or older 150 Installed? (choose one) ❑ M 1981-1991 130 Spa or Hot Tub Yes No 1992-Present 110 �� .., 1 �� �� Installed? (choose one) ❑ PARCEL INFORMATION: Topography Flat Rolling ❑ Steep Slope % Slope Soil Nature Sand ❑ Loam ❑ day ❑ Other, explain: Groundwater At what depth? �� Bedrock/Impervious material At what 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 �5-a P_ T System Absorption field w/#2 stone I 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 Septic Application 'Revised July 2022 CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL • Applicant: Name(s): MiA� ©1J Mailing Address, C/S/Z: Cell Phone: Land Line: . Email: a .QDVV\ • Primary Owners :t� Name(s): PK �a 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): Contractor Trade: 11e 0 i2+� Mailing Address, C/S/Z: Cell Phone: Land Line: Email: "Workers' Comp documentation must be submitted with this application" • Engineer(s)• Name(s): 2L)& Mailing Address, C/S/Z: Cell Phone: Land Line: Email: Contact Person for Compliance in regards to this project:, 'A UJ�q AJ Cell Phone: �1 "VS70SS 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: r�''�3 Septic Application Revised July 2022 TOWN OF QUEENSBURY 742 Bay Road, Queensbury, NY. 12804-5902 - Septic System Checklist Plan to scale AReceived Deep hole perc test results from engineer/Architect if applicable(Town Approved Engineers, Jan Architects;June 30 to April 15 Town Engineer for unapproved Engineers and Architects) t-Jb All wells on property and adjacent properties shown ftkUyl10\p l Waterline shown Municipal or well 10'separation to any part of system U Setback to property lines show 10'or more for any part of system (/Cj'//Septic tank and pump stations 10'from foundation, 50'from any well/lake/wetland, 10'from any waterline 4septic 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 Leech Field 20'from foundation 100'from any well 10'from water line i ASeepage pit 150'from well 50'from septic tank ^/Seepage Pits 3-times diameter apartSeptic 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 '�JkToe of mound or bottom of retaining wall 10'from property line, 100'from well, 20'from foundation 6�_<J Provide Engineer/Architect stamp ems V "epartment of Health Approval for all mobile home park new systems Flood Plain requirements 0 2' above established flood elevation to bottom of system It/D All tanks anchored or 2' above flood elevation Notice of Intent to Construct, NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Community Environmental Health and Food Protection Enlarge'or Convert a Facility Please read instructions on back before completing form. r�1'K;� I Proposed facility name: ...5`X ._..__.._._........--_..__ ..__.._.__......_..__........ .. ........JJ..11....... _._._._.._. .. ......__....................._..__..__...___..-;: � " - ___-- g ,� If existing,current ,`'facility name: _ `- �"' C .,.,...:..,_. ,.._.._ __.......�. _ ...._....,._. _.. . ,. Fla! The property wilt be used as: ;J Food service establishment i I Agricultural fairground �5 -1 Temporary residence j, j Migra nt fa rmwo rker horisi n ENAt6 I Children's camp ( Mobile home park V ! LJcampground i Swimming pool TOWS( Or pg l.,_.i g p DUI! -__ Mass gathering ;. . Bathing each i w ._.._..._......-.-___ County--•' �'� _ -_-- Town,Villa g"City- filew ! Renovation LJ Conversion Are plans attached? _ Yes No Detailed location(e.g.,road,street,building n er, istapce fro well known po' 5 I'd . ..._........-. Name of owner: Address: Phone:( -) g Name of operator: Address: Phone:( ) .._..__........_.._...__._...._.;. -- __....._.....�----..-_..._.................._.. ......._—._ _._...._..............._........._.._..._....-_...._._._................_._..._..-....._.--..--.--...'............_..........._.... _.-..._.._......._.--._.—.._............... It is proposed to(describe in detail;use additional sheets if necessary): 5b 1 5�� 1 The following permits or approvals for the proposed construction,enlargement or conversion have been applied for or received: 1 i Name of local code enforcement officerfor facility location: Address: Phone:( ) Date:Signature: ti w.......... ..... .....- -..._. _......._._.:. .._........._ . ,.._._.,,_._... .,.__._....._........__...._...:.- _w_...__.__........_...-...._._..__ Title: _._ ; Owner (.._._ Operator __; Other,.specify Mailing Ad ress: Phone:( DOH-154(4104)Page 1 of 2 �` (GEN-140) • • s x. aIr • � � s DESIGN DATA: DESIGN FLOW = •700 GPD FOR TWO UNITS W/ THREE BEDROOMS EACH (6 BR TOTAL) NEW'"STANDARD FIXTURES, (1.6 GPF & 3 GPM MAX.) AN ELGIN SYSTEM IS PROPOSED AS A SUBSTITUTION TO PREVIOUSLY APPROVED SEEPAGE PITS 1-5 MINUTE PERCOLATION RATE W/ APP RATE OF 1.7 G/SF 8 OUTLET DBOX W/ SPEED LEVELERS ROWS OF 7 1750 GALL DC TANK -n 2 BR DOUBLE WIDE. M08ILE HOME 70' 'A 28' I RKINGI24'X20' I 'm I c� z CONSTRUCT SWALE BETWEEN DOUBLE WIDE HOMES, GRADE SURFACE TO SWALE 70' 12' 28T I PARKINGI24'X20` SHUT OFF — — ,- - ACCESS ROAD B based 01I ours is s all 11%dficatlans with our CO he plans and s tI1ldln Codes u ltidtCalti CC IIIIII 111C New Yatk State. — — — — PLAN DOUBLE WIDE LOT SCALE 1" = 20' GRADE SURFACE TOWARDS THE SWALE o I SHUT OFF NEW YORK STATE LENS F—AL 12'-0" - �-N--IN-SITU SWALE CROSS SECTION SCALE: 1/2" = 1 Dated: Iv,a ans #E�r: s-12" TOPSOIL These p; WHITE — ANTI-SILTX FABRIC are I—elly Q,ccePie �. B43 ELGIN MAT Reviewed by' forhe-0 (;ommiss onr of Hcalit iWj'c trlil'/�`� ft1�F.iCt f tll HIAI III RNS I -Al' .5 F>1 TI't1("I't7i'I'I,`t i LOTS ORIGINALLY APPI ) FOR SINGLE WIDE HOMES, CALCULATE ADDITIONA I DOFF FOR DOUBLE WIDEHOMESAND SIZE SHALLOW S1 RAIN INTENSITY i-=2" I IOUR FOR 100 YEAR STORM ADDITIONAL AREA FOR WIDE: 980 SF / UNIT X 2 1960 SF TIME = 1 HR RUNOFF: 2" X 1960SF 53 CF (100 YR STORM) STORAGE CAPACITY OF _E IS 7 SF/FT X 55' = 385 CF. TIME FOR FULL SWALE RAIN AT, 5 MIN / IN IS 1 HOUR FOR A 12" DEEP SWAL APPENDIX 75A SETBACK TREATMENT AREA TO PRi TREATMENT AREA TO RE! SEPTIC TANK TO WATER LACES; Y LINE: 10' :E: 20' Y. 50' 4,, 1--\�N-SITU SAND GENERAL NOTES: 1. DESIGN AND ALL WORK FOR TREATMENT SYSTEN PER NYSHD APPENDIX 75-A 2. ALL ROOF OR HOUSE DISCHARGES SHALL BE DIRECTED AWAY FROM THE TREATMENT AREA. 3. OWNER/CONTRACTOR RESPONSIBLE FOR I ASBUILT SKETCH OF ACTUAL LOCATION OF COMPONENTS. .� I < < 4. PRIOR TO EXCAVATING CONTACT LAYS DIGSAFE A < 1-800-962-7962. S. PERCOLATION RATES TAKEN FROM APPROVED SEEPAGE PIT DESIGN BY VDS, 3-16-93. 7. TREES AND ROOTS SHALL BE REMOVED IN TREATMENT AREAS. 8. SEAL UNUSED INLETS OF SEPTIC TANK. 10. ALL COMPONENTS TO BE SET ON A LEVEL 12" STONE BASE.- ' 11. D-BOX TO BE 8 OUTLET W/ SPEED LEVELERS, CAULK OULTET SEALS. 12. SEPTIC TANK TO BE FM OR EQUAL W/ 4000 PR CONCRETE AND 5-9% ENT. AIR 13. WATER SUPPLY IS MUNICIPAL. GROUNDWATER OR IMPERVIOUS LAYER ELGIN DETAIL SCALE: 1/2" - 1' mRv Hartman < � as�t�glaf4Wn rr LOCATION MAP SCALE: 1 " = 3 MILES IT IS A VIOLATION OF THE LAW FOR ANY PERSON, UNLESS ACTING UNDER THE DIRECTION OF THE LICENSED ENGINEER, TO ALTER ANY ITEM OR PORTION OF THIS DOCUMENT IN ANY WAY. THE ENGINEER HAS NOT BEEN RETAINED TO PERFORM OR PROVIDE INSPECTIONS OR CERTIFICATIONS ASSOCIATED WITH THIS PROJECT. IF IN THE COURSE OF THIS PROJECT A CONDITION EXISTS WHICH DISAGREES WITH THAT AS REPRESENTED ON THESE PLANS. THE CONTRACTOF SHALL STOP WORK AND NOTIFY THE ENGINEER OR ASSUME ALL RESPONSIBILITY ARISING THEREFROM. IT IS THE RESPONSIBILITY OF THE OWNER/CONTRACTOR TO ENSURE THAT ALL MATERIAL ORDERED COMPLIES WITH PROJECT REQUIREMENTS. 0 RYAN M. BURNS, NYS P.E. LICENSE No. 084062 DESTROY PREVIOUSLY DATED DRAWINGS A° 1 12/14 RB ENG. COMMENTS ¢ NO. DATE I BY REVISIONS UPSTATE DESIGN ASSOCIATES RESIDENTIAL DESIGN AND CIVIL ENGINEERING " RYAN M. BURNS, P.E. IRA S. ALTER, P.E. 180 PLEASANT STREET 10 MADELINE DRIVE r Fae KEESEVILLE, NY 12944 SARATOGA SPRINGS NY t9t P:518-572-0256 518-573-2549" 128E ,.Odt R 518-536-9058 QUEEN5BURY VILLAGE MHF aynvt PROJECT: ELGIN SEPTIC / RUNOFF DESIGN LOCATION: PETRIE LANE, QUENSBURY NY DATE: 10/10/07 DRN. BY RMB SHEET NO. 1 GENERAL NOTES: )ESIGN DATA: DESIGN FLOW=•700 GPD FOR TWO UNITS W/ THREE BEDROOMS EACH (6 BR TOTAL), N ez, !STANDARD FIXTURES, 1.6 GPF & 3 GPM MAX. AN ELGIN SYSTEM IS PROPOSED AS A SUBSTITUTION TO PREVIOUSLY APPROVED SEEPAGE PITS 1-5 MINUTE PERCOLATION RATE W/ APP RATE OF 1.7 G/SF (28) 843 ELGIN MATS REQ'D, (4) ROWS OF 7 8 OUTLET DBOX W/ SPEED LEVELERS 1750 GALL DC TANK en CD C jjj r CA IV C U J 0, v) IZ rp ® C ° ci6 in a rx c9 BR DOUBLE0. IDE MOBILE [HOME u�y EM CONSTRUCT SWALE BETWEEN DOUBLE WIDE HOMES,'GRADE SURFACE TO SWALE 70' 0 1 N 12` 'o 28° � 28° a- I I 7 1 I PARKINGI24'X20' I' I PARKINGI24'X20° I �� r 55.00' SHUT OFF �t�i I)F 'TO�NN OF Qt.1E.ENSB U U)ING IPAITMEk (lance Eased ()n OUr I,,,,,d EY8UIS08tlalla COm;) ACCESS ROAD B with our camments�saInd $ edfic t onsu areaIII — 'IC1d0t' C e lull compliance vJith eta+gyp PLAN —DOUBLE WIDE LOT I�B`,N YOf1 S.�,e SCALE 1" 20' GRADE SURFACE TOWARDS THE SCALE a- 1 OFF SEED '—�N—SITU SAND --�� SWALE CROSS SEC710N SCALE.1/2" = 1' NEW YORK STATE LENS FAL Dated a These plans ere hereby A,cceo' Reviewed by: for the MAY i'J}'r� i)f:'�r1;� r�hil I�'i't)i• H!_Al 1•F1 � { t.l�1� f/i];t.S"()ISt•t'tIC"1`t)I�I�K'i� i LOTS ORIGINALLY APPI 3 FOR SINGLE WIDE HOMES, CALCULATE ADDITIONA DOFF FOR DOUBLE WIDE HOMES AND SIZE SHALLOW 51 RAIN INTENSITY :-=2" I IOUR FOR 100 YEAR STORM ADDITIONAL AREA. FOR WIDE: 980 SF / UNIT X 2 = 1960 SF TIME = 1 HR RUNOFF: 2" X '1960SF 53 CF (100 YR STORM) STORAGE CAPACITY OF E IS 7 SF/FT X 55' = 385 CF. TIME FOR FULL SWALE RAIN AT, 5 MIN / IN IS 1 HOUR FOR A 12" DEEP SWAL APPENDIX 75A SETBACK ! NCES: EATMENT AREA TO PRE EATMENT AREA TO RE F Y LINE.10' :E° 20' PTICTANK TO WATER "-�—IN—SITU SAND GROUNDWATER OR IMPERVIOUS LAYER ELGIN DETAIL SCALE: 1/2" - 1' 9 1. DESIGN AND ALL WORK FOR TREATMENT SYSI PER NYSHD APPENDIX 75-A 2. ALL ROOF OR HOUSE DISCHARGES SHALL BE DIRECTED AWAY FROM THE TREATMENT AREA. 3. OWNER/CONTRACTOR RESPONSIBLE: FOR ASBUILT SKETCH OF ACTUAL LOCATION OF COMPONENTS. 4. ;PRIOR TO EXCAVATING CONTACT NYS DIGSAFI 1=800-962-7962. 5. `PERCOLATION RATES TAKEN FROM APPROVE[ SEEPAGE PIT DESIGN BY VDS, 3-16-93. 7. TREES AND ROOTS SHALL BE REMOVED IN �"TF EATMENT AREAS. 8.+ SEAL UNUSED INLETS OF SEPTIC TANK. 16. ALL COMPONENTS TO BE SET ON A LEVEL 1 S ONE BASE. 1 D—BOX TO BE 8 OUTLET W/ SPEED LEVELEI CQ,ULK OULTET SEALS. 12. SEPTIC TANK TO BE FM OR EQUAL W/ 4000 CONCRETE AND 5-9% ENT. AIR 13. WATER SUPPLY IS MUNICIPAL. IT IS A VIOLATION OF THE LAW FOR ANY PERSON UNLESS ACTING UNDER THE DIRECTION OF THE LICENSED ENGINEER, TO ALTER ANY ITEM OR PORTION OF THIS DOCUMENT IN ANY WAY. THE ENGINEER HAS NOT BEEN RETAINED TO PERFORM OR PROVIDE INSPECTIONS OR CERTIFICATIONS ASSOCIATED WITH THIS PROJEC' IF IN THE COURSE OF THIS PROJECT A CONDITIC EXISTS WHICH DISAGREES WITH THAT AS REPRESENTED ON THESE PLANS. THE CONTRACI SHALL STOP WORK AND NOTIFY THE ENGINEER C ASSUME ALL RESPONSIBILITY ARISING THEREFRf IT IS THE RESPONSIBILITY OF THE OWNER/CONTRACTOR TO ENSURE THAT ALL MATERIAL ORDERED COMPLIES WITH PROJECT REQUIREMENTS. RYAN M. BURNS, NYS P.E. LICENSE No. 084062 DESTROY PREVIOUSLY DATED DRAWINGS i€ t "r" 41E 1 1 12/14 RB ENG. COMMENTS N0. DATE BY REVISIONS UPSTATE DESIGN ASSOCIATES actin 1 s RESIDENTIAL DESIGN AND CIVIL ENGINEERING RYAN M. BURNS, P.E. IRA S. ADLER P.E. 180 PLEASANT STREET 10 MADELINE DRIVE Hartman : C' rii. "' a KEESEVILLE, NY 12944 SARATOGA SPRINGS P: 518-572-0256 518-573-2549 12 banivlaeayan P, cnr S� r" Fe waodr I g F 518-536-9058 QUEENSBURY VILLAGE M. tfIQ , , ; •I M y > ( : R ! Rayno!' ® rn. .. PROJECT: ELGIN SEPTIC RUNOFF DESK LOCATION: PETRIE LANE, QUENSBURY NY LOCATION MAP SCALE: 1 " = 3 MILES DATE: 10/10/07 DRN. BY: RMB SHEET NO. — DE, GN FLOW � -700 GPD FOR TWO UNITS W/ THREE BEDROOMS EACH (6 EIR TOTAL) NEW%ANDARD FIXTURES. (1.6 GPF & 3 GPM MAX.) AN ELGIN SYSTEM IS PROPOSED AS A SUBSTITUTION TO PREVIOUSLY APPROVED SEEPAGE PITS -5 MINUTE PERCOLATION RATE W/ APP RATE OF 1.7 G/SF (28) B43 ELGIN MATS REQ'b. (4) ROWS OF 7 8 OUTLET DBOX W/ SPEED LEVELERS 1, 750 GALL DC TANK 10 \NG \w 6 \0\0 hat mot dMr-allul- s 0 code 'aim mmo\ks I oo G e V\�AiSkj the 5\c e '10 11 cO of 10 13'- 0 C c: 1, ca 2 BR DOUBLE z 0 WIDE MOBILE i HOME to 70' 12' 0, <VIG124`*X20' I T"�, r_ 13'-6"- CONSTRUCT SWALE —BETWEEN DOUBLE WIDE HOMES, 'GRADE SURFACE TO SWALE 70' SHUT OFF ACCESS ROAD B PLAN - DOUBLE WIDE LOT SCALE 1 " = 20' 28' PARKING 1 2020' GRADE SURFACE TOWARDS THE SWALE O Mm �N-SITU SAND SWALE CROSS SECTION SCALE: 1/2" NEW YORK STATE ITMENT OF HEALTH IT- 0 "M n�,,: • • NE BASE. BE 8 OUTLET W SPEED LEVELER5 06C110 rt%L I iIMGT 01+VE MOUND TOPSOIL TO ALLOW FOR SETTLEMENT Date& TOPSOIL These glans for.1 w WHITE ANTI-S I � Ii 4IN Y dw FABRIC are hereby AcceF B43 ELGIN MAT ReViewed by: _e . I . for th( I ugmmitsir, oner of Hoalt IN-SITU-SAND— ly 1 .9 2016 Ny< RTMh'N*1'()I.HhA1 I'll 01,37A ICT 011,10. LOTS ORIGINALLY CALCULATE ADDr FOR SINGLE WIDE HOMES, AND SIZE SHALLI 1OFF FOR DOUBLE WIDE HOMES RAIN I NTFNSITY. ADDITIONAL ARE/ ]OUR FOR 100 YEAR STORM 1960 SF WIDE: 980 SF / UNIT X 2 TIME -.1 HR RUNOFF: 2" X IS STORAGE CAPACI 53 CF (100 YR STORM) 'TIME FOR FULL S I _E IS 7 SF/FT X 55- = 385 CF. FOR A 12- DEEP RAIN AT, 5 MIN / IN IS 1 HOUR 4' PERFORATED PIPE-J •"iN-SITU SAND GROUNDWATER OR IMPERVIOUS LAYER ELGIN DETAIL SCALE: 1/2" - I' to C4 IT IS A VIOLATION OF THE LAW FOR ANY PERSON, UNLESS ACTING UNDER THE DIRECTION OF THE LICENSED ENGINEER, TO ALTER ANY ITEM OR PORTION OF THIS DOCUMENT IN ANYWAY. THE ENGINEER HAS NOT BEEN RETAINED TO PERFORM OR PROVIDE INSPECTIONS OR CERTIFICATIONS ASSOCIATED WITH THIS PROJECT. -,ds APPENDIX 75A SE* Wm NCES: RvA "L 4_0Z.N .1. TREATMENT AREA' N TREATMENT AREA' Y LINE: 10. AR 0 mm�;m SEPTIC TANK TO W :1- 20' f wx ti Nk-1 'OFF A M a jab IT IS THE RESPONSIBILITY OF THE OWNER/CONTRACTOR TO ENSURE THAT ALL MATERIAL ORDERED COMPLIES WITH PROJECT REQUIREMENTS. RYAN M. BURNS, WS P.E. LICENSE No. 084062 DESTROY PREVIOUSLY DATED DRAWINGS 1 1 12/14 1 RB I ENG. COMMENTS �N=o.DAT T­BY I REVISIONS UPSTATE DESIGN ASSOCIATES RESIDENTIAL DESIGN AND CIVIL ENGINEERING RYAN M. BURNS, P.E. IRA S. ADLER, P.E. 180 PLEASANT STREET 10 MADELINE DRIVE KEESEVILLE, NY 12944 SARATOGA SPRINGS t P: 518-572=0256 515-573-2549 1" 518-536-9058 QUEENSBURY VILLAGE M IN SEPTIC / RU PROJECT- ELC NOFF DESI LOCATION:• PETRIE LANE, QUENSBURY NY DATE: 10Z10Z07 ..__ DRN. BY. RMB SHEET NO. —