SEP-0767-2023 SEPTIC DISPOSAL PERMIT Office Use Only
APPLICATION Permit#: �' O\} -2• '2)
Townn of
ofQuecnsbury E� C OV ermit Fee:$ 5
Invoice#:
742 Bay Road,Queensbury,NY 12804 DEC 0 5 202
P:518-761-8256 www.queensbury.net Septic Variance 014
TOWN OF OUEENSBURY
BUILDING CODES Flood Zon,: No
Wetlands? O Reviewed B
Project Location: 2S Ce a.i'ivooel DR
Tax Map#: Z% .q -2 - 23
RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms: X gallons per =total daily flow
per day bedroom , Garbage Grinder Yes No
1980 or older 150 tj ( 0 0 Installed? (choose one) ❑
1981-1991 130 Spa or Hot Tub Yes No�
1992-Present 110 Installed? (choose one) ❑ I✓I
PARCEL INFORMATION:
Topography 126at Rolling ❑ Steep Slope % Slope
Soil Nature [ and ❑ Loam ❑ Clay ❑ Other, explain:
Groundwater At what depth? 0'
Bedrock/Impervious material At w at depth? 0"
Domestic Water Supply grMunicipal ❑ 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 toe o 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 L/ 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
It.oK,y,G 1-0 Pt I e 1.11i T 4
Septic Application Revised July 2022
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
'Name(s): t$S Sep/-,c t pry.r.
% Mailing Address, C/S/Z: Z L.wor 'Mae„ 5 t
Cell Phone: 7 rl62-0%5'6 Land Line: Sty- 795—`$v9 '
Email: e51.p/ey •r®w..
• Primary Owner(s):
Name(s): I li Q r4 Y le 1
Mailing Address, C/S/Z: Zf ood IPr
Cell Phone: Sits•746— R 4 S{o Land Line:
Email: yo l,e trq:n 3 3 l/4 too, Co m-•
Check if all work will be performed by property owner only
• Contractor:
Contact Name(s): .2"g5 SPp 'c f Arg,
Contractor Trade: PILM.1s . t nrc.`r,
Mailing Address, C/S/Z: Z yoi_. 14"ter^ Sf
Cell Phone: Si 96-1 c/!o-0$5(, Land Line: if
Email: '54'2/rya ;b55o 1 -t,(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: (Ric J 5ii p/c'y
Cell Phone: 5`i el' 7 cfG c2 Th Land Line: cr S-79 '- g/9 y
Email: e514.prey
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: to f1/.?IPr
SIGNATURE: -(/"—' et DATE: 17,1'117 3
Septic Application Revised July 2022
TOWN OF QUEENSBURY
742 Bay Road, Queensbury, NY. 12804-5902
Septic System Checklist
do Plan to scale
4/4 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)
N6 All wells on property and adjacent properties shown
rASWater line shown Municipal or well 10'separation to any part of system
f-PAetback to property lines show 10'or more for any part of system
Cf cSSeptic tank and pump stations 10'from foundation, 50'from any well/lake/wetland, 10'from any waterline
AI A 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
y7i--S Leech Field 20'from foundation 100'from any well 10'from water line
NJ A Seepage pit 150'from well 50'from septic tank
A/ASeepage Pits 3-times diameter apart
- Septic tank and pump stations over 30 gallons 50'from watercourse or wetland
1 Distance from bottom of trench or system 24"to bedrock or mottling 36"within 1000'of Lake George
(fa Leech field 100'from watercourse or wetland
NA. Toe of mound or bottom of retaining wall 10'from property line, 100'from well,20'from foundation
'J 0 Provide Engineer/Architect stamp for bed or design systems
I`�/� Department of Health Approval foe)all mobile home park new systems Flood Plain requirements
NIA; 2'above established flood elevation to bottom of system
1.4 All tanks anchored or 2'above flood elevation
,,can / F
ce -5
I i 1 r I i \ -`(-� f
11
-- fin, ,i I ° i i I i
7L— : , , ! __,-----, , ,jv ' . . ,
' ,p i • • I .
•
, . ...-i-‘ A ! ' I 1 I ' !
I'�C�"�� C4 1 Al 1 I' �1 ' I I--( ,I d m��l.,�.z.. _ `I�-�• .
•
• - in )NO i/Pq cti VePt e 1 I� I I� i Ii
1 ; i I L� i II II IWVi 0.A1-1a"6 I II I I.
I— pc,o1W i ! Ic,ri 1
0
j___: I r Ovvi�t ut= tJi.EoiEsl3tlRY I •_ _ _ I i ' Utl-I�i{ jt R, / rt^o[.c ! 1
• IMF� � —. = `� { 11
1 j I i i I I
•I i j ' I I i
•
•
�JESBU�`Y a rq e •
TAN OF QUEEN BURY •
TO' I CO®E DEP�. ;— c,4 e i gUILDINC DEPARTMENT
�I n ; , Based on;our limiter exaininakIon t;omuliance
•
i with our comments shall:nct he construed as
--- Vt�' 1 mdicyeting:the plans',nes P incationsfare in
_— ; ,• full Qom fiance with the quil ing of
Codes
Date: - -. ; , I ew Yo�c State.
1 •i i - i
I i • I i i ' —� i i I
•
i ' ' M r _'' 1 •
-- ---_i i I i i I i
—' ---• • acr �} —E 296.9-2-23 SEP-0767-2023
E� Yole, William
-- I LE i i 25 Cedarwood Dr
. Residential Septic Alteration
•
i i • I I _
•
—_T
• -- I i I I 1 ( { i
__ i � iY �•V \ i ' I ' I I f
...
•
, -7--
Q
_.-
_ ....------------A
d (N)
/ --E__i-_---=:--: --,
----- • •Elf.:. , ; ,:,•-:.,..s 7 ,, r /7
• 1 C'''-' V".' i• , c-,---,,‘ 1-0 , ,
• --- iz-z ‘ -:''-'-' \
L .
--
1[1:1 i-- ----i
• -:-:' ' 0 i'Z's\ Cl.' --g
1 ‘11--;•-r.r.A 0
ti Q
r .. 1\1 L__.---. c•-....2 \
--- . — ,
* '4 -"
\r_ii-L.---.--:
__________— . _
• 3 (-NI° c6
. . .
i - \i
. .
foe ...........
-
_
—1 1C-
1 t 4/---
....
0
1 \
•
tP CP
. 41
.5.
. OP
..t.' 0
..1
-F9;1
a
- -
. .
t- .
..
0° C•011.
...,_....,,
\ . _
..._ ' __........_mm
..,---
• _ ___. _____