SEP-0485-2023 SEPTIC DISPOSAL PERMIT Office Use Only
APPLICATION Permit#: D�- 0!%5-20 26
Townot'cZccnstiury Permit Fee:$
,_..._ _.__......R,. "
Invoice#: (44< (o
742 Bay Road,Queensbury,NY 128
P:518-761-8256 www. ueensbu n AUG 0 4 202} Septic Variance DNO
T OWN OF OUEENSBURY Flood Zone?
BUILDING&CODES I Wetlands? � Reviewed By:
Project Location: N 5 f
Tax Map #: 3 0 • l o -2 —S2
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 33 p Installed? (choose one) ❑
PARCEL INFORMATION:
Topography lat Rolling ❑ Steep Slope % Slope
Soil Nature and ❑ Loam ❑ Clay ❑ Other, explain:
Groundwater At what depth?
Bedrock/Impervious material At what depth?
Domestic Water Supply gMunicipal 0-416+ ❑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 Joao 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 If C> ft.; Each Trench So 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
1
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): fes fen Ac i Dams,•„
Mailing Address, C/S/Z: Z LV(-e' WQrre- sf
Cell Phone: fiq- -7 96-o8f4 Land Line: 11- WI- $/9y
Email: iPf�le /��.<a
• Primary Owner(s):
Name(s): 6-- ✓bi,g klaod4, d
Mailing Address, C/S/Z: rti•►.
Cell Phone: Land Line:
Email:
❑ Check if all work will be performed by property owner only
• Contractor:
Contact Name(s): ::P91 SPa J.'r t Pam•`.,
Contractor Trade: fPa l• �
Mailing Address, C/S/Z: 2 �v�•.�,. fy�rrP• sf
Cell Phone: 'fit- -7 46-o-Sf i6 Land Line:
Email: Ps4,'.p(P
**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: e��e-IJ�Y��
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 all
requirements of the Town of Queensbury Sanitary Sewage Disposal Ordinance.
PRINT NAME: Ei i C �_ 5'���D 4�.
SIGNATURE: DATE: 31 23
Septic Application Revised July 2022
01�
TOWN OF QIIEENSBURY
742 Bay Road, Queensbury, NY. 12804-5902
Septic System Checklist -
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)
r� All wells on property and adjacent properties shown
dater line shown Municipal or well 10'separation to any part of system
,getback to property lines show 10'or more for any part of system
:6eptic tank and pump stations 10'from foundation.50'from any well/lake/wetland 10'from any waterline
rJ" eptic 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
"Seepage pit 150'from well 50'from septic tank
I�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
�eech field 100'from watercourse orwetland
Toe of mound or bottom of retaining wall 10'from property line 100'from well 20'from
Foundation
wprovide'Engineer/Architect stamp for bed or design systems
&AVepartment:of Health Approval for all mobile home park new systems Flood Plain requirements
I"02'above established flood elevation to bottom of system
II tanks anchored or 2'above flood elevation
. �s• ro.i d��ZY7n71
TOWN --�----- --------,--
- BI,hILDI F EE SBWRY 1 I
�G EPA TM NT--- ---- -- - — — - - -- -- - --- — -- — --— --- - -- - -- - ;
Based n o r limited_xam�_atioi,co pli nce
I r comments s all n t_b con true -as —�- ---- ---- - ----- --.I-- - -- - I- - ------ ---
tho� sae in
wl ns_ n
indicat�jg the-PI , d s, eci catlo odQs-o{_ _ _______
f II c mph nce with the uwf ing-- I
--- ew�ork- wte:� — —I
o -
�, -- - - -
COFC _iI__�_ ._ i_
jjL
a s �+ 1� --� ��— I I
- a o a r� I -
--
- V) � 19
-- _�_ _�— a — —�--— ----I— --
j_ f i
ncr
- JMOF- - - ---- I _QJEENSBbm RY �— -..---,---1- --�--�---(- � -_�- -- --
- o �--►-- I —I I_ U I D N GC CI_Da- EIPT.Le\ . W, I
--
o
cm
W -- -� - I --I--- ,-I- - -- f_ _►-1_--- �_i __
_ , � I ( _ _.�—[_����Imo—�--— — — �_—, _ � _►—( _ I —1-----
� ��l_I__ !_�_�_ I__�_�-1►_�.__i_ ►__i____�_ �___ _ _�- ! a ___ _�._�__�_ Imo___
--�--
.
LIB f �� Tr-,