SEP-0430-2023 SEPTIC DISPOSAL PERMIT office Use only
APPLICATION Permit#: 8°�'3�— 219 2 3
Town ofQucensbury [41,
I. C E O W E Permit Fee:$ �5
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L q 4 Invoice#: (2.
742 Bay Road,Queensbury,NY 128 9 � � CN
P:518-761-8256 www. ueensbu Septic Variance? Y 0
OWN OF nUEENSBURY J
E�UILDING &CODES Flood Zone? Y 4u%
Wetlands? Y -(:51 �> Reviewed By.
Project Location: 13.3 Ape //;ll eel c�
Tax Map #: 251 . -7 — I Sa
RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms: X gallons per =total daily flow
per day bedroom Garbage Grinder Yes No
1980 or older 150 3- 1.�1r'D Installed? (choose one) ❑
1981-1991 130 Spa or Hot Tub Yes No
1992=Present 110 .
Installed? (choose one) ❑
PARCEL INFORMATION:
Topography [mat Rolling ❑ Steep Slope % Slope
Soil Nature Usand ❑ Loam ❑ Clay ❑ Other, explain:
Groundwater At what depth?
Bedrock/Impervious material At what depth?
Domestic Water Supply ❑ Municipal ell ❑Lake
(if well or lake, water supply from any septic system absorption is
vo 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
System Absorption field w/#2 stone Total length ft.; Each Trench ft.
Seepage Pit w/#3 stone How many: 2 ; Size:
Alternative System Bed or other type:
Holding Tank System Total required capacity? ; tank size ;
# of tanks
V wP I4-- t 1 $P Rpp/4 t : y -� p �� �o x a n
1 4r I V1 PS to N oyylvP t( OAS .
Septic Application Y Revised July 2022
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): R R-c I*Cf f-ey
Mailing Address, C/S/Z: 2 low., V4110, Sf
Cell Phone: fi j- -7V 6-O49f"�o Land Line_: f"K - 7?1-T/9 y
Email: pS Ir:+O/t art fP /•f Co.-r
• Primary Owner(s):
Name(s): IMaf,F hew 4 bfr
Mailing Address, C/S/Z: 1T3 Tre 14-11 Rb 40 00'
Cell Phone: 51'%-4(vR•3Z7S9 Land Line:
Email:
❑ Check if all work will be performed by property owner only
• Contractor:
Contact Name(s): fff SSA f,'t t AN:n
Contractor Trade: PA my GJ»y f Si f'C
Mailing Address, C/S/Z: Z b/lyen f f 9P'f
Cell Phone: !ri J&- 7 V k-O g S'6 Land Line: !�`$ - 7�t 4- T/9 y
Email: P 4.` /p v a ;` f#- J o
"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: Ef4;C T 5*4.119le
Cell Phone:IItr 06- -] V 6-01F (o Land Line:
Email: ?1 h•0 te,IF F
a7+ h5 �PD�•C• (co...
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.
PRINTNAME: E14+'C
SIGNATURE: DATE:
Septic Application Revised July 2022
\`v
TOWN GF QUEENSBURY
742 Bay Road, Queensbury, NY. 12804-5902
Septic System Checklist
WPlan to scale
Received Deep hole pert test results from engineer/Architect if applicable(Town Approved Engineers and
Architects;June 30 to April 15 Town Engineer for unapproved Engineers and Architects)
IgAll wells on property and adjacent properties shown,--2�
Eater line shown Municipal or well 10'separation to any part of system
Setback to property lines show 10'or more for any part of system
Aseptic tank and pump stations 10'from foundation 50'from any well/lake/wetland 10'from any waterline
"__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
Leech Field 20'from foundation 100'from any well 10'.from water line
—Xieepage pit 150'from well 50'from septic tank 5
i!aSeepage Pits 3-times diameter.apart
-6p Septic tank and pump stations over 30 gallons 50'from watercourse or wetland
Sistance from bottom of trench or system 24"to bedrock or mottling 36"within 1000'of Lake George
�)KLeechfield 100'from watercourseorwetland
i/ WToe of mound or bottom of retaining wall 10'from property line 100'from well 20'from
Foundation
lam" Provide"Engineer/Architect stamp for bed or design systems
t'qDepartment 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
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[� `- i 1 i TOWN OF QCJE;ENSBOR
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ElLDINGIDEPARTMENT i
i --�i- Based on our Ilmlted examination,compliance I ii
289.7-1-l50 '!o—� _vvitliou�commeDts shall not be construed as I ( I
SEP-0430-2023 i (�ii indicating ;the plans aid Is ecifications are in
I I I I I -fWl=compliance with�he - uilding!_Codes�of
Eberlein, Matthew
f . I
133 Tee Hill Rd New��� I i !York State i
Residential Septic Alteration
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