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SEP-0202-2023 SEPTIC DISPOSAL PERMIT office use only APPLICATION Permit#:- -02oz, —z� Town of Qucensbury (� I�.E U W Permit Fee:$ �d Invoice#: ��b� 742 Bay Road,Queensbury,NY 12804 6g tlt7 P:518-761-8256 www.queensburv.net _ 1 Septic Variance? Y TOWN OF 0UEE__N3SURY 6Uit D,1NG n;C_0gE: ; Flood Zone? Y N Wetlands? Y Reviewed By: Project Location: 8 U►e_p_t�'J Y U l 2— P � Tax Map #: -' t 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) ❑ [� 1981-1991 130 Spa or Hot Tub Yes No 1992-Present 110 _�� ,[ (vl Installed? (choose one) ❑ PARCEL INFORMATION: Topography Flat Rolling ❑ Steep Slope % Slope Soil Nature Sand ❑ Loam ❑ Clay ' ❑ Other, explain: Groundwater At what depth? �3f)� — 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) 52-e kt�P:,5l PROPOSED SYSTEM INFORMATION: Tank size gallons (min. size 1,000 gallons, add 250 gallons for each garbage cylinder or spa/hot tub -5,P,P, 1 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 Septic Application Revised July 2022 CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL • Applicant- Name(s): lTGIy©� Mailing Address, C/S/Z; �13�4 0'9 Z..M-0� Cell Phone: Sr t),F>--rl W Land Line: , �7q!6,2z�) Email: a .QDvv\ • Primar Owners : Name(s): 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): lit) Ad Contractor Trade: ij9—16 ellz_ Mailing Address, C/S/Z: Cell Phone: Land Line: Email: **Workers' Comp documentation must be submitted with this application** • Engineer(s)• Name(s): Mailing Address, C/S/Z: Cell Phone: Land Line: Email: Contact Person for Compliance in regards to this project: YI/� yLJ�klT�v� Cell Phone:,j1 1.57 OS'? 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:--7- 3 Septic Application Revised July 2022 TOWN OF QUEENSBURY 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 En ineers a d Architects;June 30 to April 15 Town Engineer for unapproved Engineers and Architects)arm En -6 All wells on property and adjacent properties shown Wwater line shown Municf aI or well 10'separation to any part of system Setback to property lines show 10'or more for any part of system vk—Septic tank and pump stations 10'from foundation, 50'from any well/lake/wetland, 10'from any waterline -�5eptic 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) 1�YSeptic tank sized for number of bedrooms and add 250 gals for Jacuzzi tubs/garbage grinder each 14Leech Field 20'from foundation 100'from any well 10'from water line — eepage 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 Distance from bottom of trench or system 24"to bedrock or mottling 36"within 1000'of Lake George �1-PiS Leech field 100'from watercourse or wetland +� Toe of mound or bottom of retaining wall 10'from property line, 100'from well, 20'from foundation W.- rovide Engineer/Architect stamp f s epartment 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 Notice of Intent to Construct, NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Community EnVironmentaI Health and Food Protection Enlarge;or Convert a Facility OEM Please read instructions on back before completing form. Proposed facility name: ._____.__..__._-- .- -__--._-_- --___..__..__� _ __ -- -� • .! - _ Vy__ �' �� 1. ._ If existing,current facility name: q . .__.,..._...._......_ .._.__..,....,_._ ., .............,.__._ _ ?_II J; b The property will be used as: j Food service establishment i_., Agricultural fairground 2023 ID Temporary residence Migrant farmworker •otisT , - -� Children's camp. 15 ; Mobile home ark _ L UIL �l(� a r ENSBU ' CODES 1 Campground Swimming pool t..._i '-i-Mass gathering . .I Bathing beach Town,village al City: Qlew ( Renovation ?.._,i Conversion — Are plans attached? __. Yes i .. No Detailed location(e.g.,road,street,building n er, istapce fro well known po' — Name of owner: Address: Phone!( ) �'� j Name of operator: I Address: Phone: t -yv It is proposed to(describe in detail;use additional sheets if necessary): af. t b7 The following permits or approvals for the proposed construction,enlargement or conversion have been applied for or received: fi 1 • Name of local code enforcement officer for facility location: Address: — ——^ Phone:( ) _.,..._..._........ ......... _. _..- -..._ _.. _ _.,......._..._.._..._..__....._.-._._.._._.... ._......._ ......_. ..._. .. ._ Date:Signature: Title: _ ! Owner ._._i Operator ; Other,.specify _-- Mailing Ad ress: Phone:( 5 DOH-154(4/04)Page 1 of 2 �` (GEN-140) 't { 3 ; r D .;; O I` tn m m �f,j = i c mom rn O y �a.�- g,3-o o'53G0� d�oCO frn2�-n �y.m Naco aQG m dp;; 7 d.-'•o� o W 55' LONG I Z O O d �dty 7 U o 1�cp ln:EmA . 5c zo m 6 • W mac ocn o �("rm-D m mm m 'q)-IN20-i-'D 70 m3oz��vv DAr zvrD-o D��ouaoioz tn�o nzm r�Mm'� '-n DNx rD-Z, rrm-4 V)mZ vC 0 D yr ztnA m11 to -no ON_ J G N O p;0 ;oZ = �.r 20'-0 �N =m m eoCD- CD m CD. CD' � (D CD 0 9 ` m Cl) A -n > xt z °7 O O OD yy CAO I rmn Z:-gq rc* wZZ z W mzZ rr-vm�-ounv0p s np—b-0ttjrU)m D VxZm r-tro II Z mo r. : v T`�-D1 6 tng Op m mmv m0 DAD °v�nv rFi 3! ��p Q--4 m. r,rv.m om m�� �jj-Opp m� D D-nz O fl C w in �M� o _ O m V -4 m t7 O m n m '' `� o c to -rc � � x D W O M rn v p D 308.6-1-61 SEP-0202-2023 Queensbury Village/Wahnon 51 & 52 Petrie Ln Residential Septic Alteration G Odj7.50' N r r � , �� ON p f O �� 3mm N �N bo- mmC r dra �i- A v En . 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