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SEP-0299-2023 SEPTIC DISPOSAL PERMIT Office Use Only -7 APPLICATION Permit#: 5&12, 0 Town or(kicensbilry Permit Fee:$ Invoice#: 742 Bay Road,Queensbury,NY 12804 C E 0 W P:518-761-8256 vvww.g1u!eensrburv.net D- Septic Varian(Pc - 0, Flood Zone? 0 FrRlFJUN 05 12023 i Wetlands? 0 Reviewed By: . i 0 COVVIN 0,7 0,IN—N,�E3,U RY Project Location: 0,'1) 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 Installed? (choose one) ❑ 1981-1991 130 Spa or Hot Tub Yes No 1992-Present 110 S Installed? (choose one) ❑ —---------- PARCEL INFORMATION:, Topography lat Rolling E] Steep Slope % Slope Soil Nature [jKa n d [I Loam F-1 Clay 0 Other, explain: Groundwater At what depth? Bedrock/impervious material At what depth? Domestic Water Supply &Kvlunicipal F-1 Well E]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/hottub �Iv51 N T,119� System Absorption field w/#-'2 stone 'Total length 1570 ft.; Each Trench 5 c) 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 CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL • Applicant:' - Name(s): :r8f f DA�C tOrg�n Mailing Address, C/S/Z: 2 Lour f�+rr�� ft P�f�'1' wr Cell Phonel: S°�`�^- ?�0(-O�S6 Land Line: 5'& 7f�-�d19 y E m a i l: pS h.� c(I h 5-912 C, G, -►- /rT Primary Owners : Name(s): 5' 4nP Mailing Address, C/S/Z: 5'2 CID ©RYwY Cell Phone: '�tlt---145- g336 Land Line: Email: ❑ Check if all work will be performed by property owner only ® Contractor: Contact Name(s): eS rite f is 4 Dr;:r Contractor Trade: 6..5 Mailing Address, C/S/Z: 2 �� lvarv�?� Q/jY"T Cell Phone: �$' -7 y(p'o S6 Land Line: Email: f5h."24 a i b5 C111 **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: , F)D� X— 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 a requirements of the Town of Queensbury Sanitary Sewage Disposal Ordinance. PRINT NAME: ER1C T sn� Q1eY SIGNATURE: DATE: 7i7j (awTOWN OF QUEENSBURY 742 Bay Road, Queensbury, NY. 12804-5902 Septic System Checklist Plan to scale lU� Received Deep hole perc test results from engineer/Architect if applicable(Town Approved Engineers and I Architects;June 30 to April 15 Town Engineer for unapproved Engineers and Architects) N All wells on property and adjacent properties shown scar-,66 eater line shown Municipal or well 10'separation to any part of system etback 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 a.1�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 5Leech Field 20'from foundation 100'from any well 10'from waterline 41JSeepage pit 150'from well 50'from septic tank Seepage Pits 3-times diameter apart 'y-eS Septic tank and pump stations over 30 gallons 50'from watercourse or wetland 4=Distance from bottom of trench or system 24"to bedrock or mottling 36" within 1000'of Lake Georg Leech field 100'from watercourse or wetland 4Toe of mound or bottom of retaining wall 10'from property line, 100'from well, 20'from foundation Ii L)Provide Engineer/Architect stamp for bed or design systems 0 V Department of Health Approval for all mobile home park new systems Flood Plain requirements 00 2' above established flood elevation to bottom of system Nf All tanks anchored or 2' above flood elevation pp� J'P 'Z V7 --7 Ail is phra It eA%ni V, A G '-I 0! L--J. TQWN OF QU--.,'EENSOURY I B ' ILOING GORES DEPT. 1 Lj) 1 R6vi§\jVod YR Dote T .2; PO Ln wl Lu CD Ln 00 CD M (Z Ln _V1I CY) (A i, o. i I i � i i—I i I I � I I — I ! � i I I ^1 I-- r) (D J U) NS8URY, m CD IqVN'OF QUE L"—L, N) B 8sedon our limited examinati�n,com plibncel VVILII IJUI W111111t:11LO 011011 ljVL UW UUIIOLIUqU Clol o I irk icatlng toe plans and SVcificaflqns ate q N) IUII LU L;V.IIIplIqIIUt:;:VVILlIj UIV! .jr ;��UO ul! I i New York Itate. I IN 1 JOB Si co` S hy. St N,,n.,C-,P, � s SHEET NO. OF WATER • WASTEWATER • STORMWATER CALCULATED BY DATE SOLUTIONS SCALE ' S* - i e2I 1 ly- El ------------ ' I I I � �� se_�rs.�=�R• + �� 9 Aft %Too > m-lagea c�A — of"mom I.. ( ( I 1: r W•s e'ree®e.��mw�BNr• "dl�� i��7 � ® rF�; >1d�f I�1� {� 1 'Y