Untitled •
SEPTIC DISPOSAL PERMIT Office Use Only
APPLICATION Permit#: .-00 3 %Zmz_-it
Town of Qyccnsbury r- $ 2 ,
--� __-_.-•. Permit Fee: Vr/
!Invoice#:
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensburv.net JAN ' � i Septic Varianc' NO
Z�.� ,./ C
_ ..- I Flood Zone?
BUILI_lii,;., ' 1 Wet lands? 1 p Reviewed By.
Project Location: 36 LO)d1 r912. pd
Tax Map #: 3607L j-7—(-- a vl
RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms: X gallons per =total daily flow
per day bedroom Garbage Grinder Yes No
1980 or older 150 6 ob Installed? (choose one) ❑
1981-1991 130 Spa or Hot Tub Yes N
1992-Present 110 , - - - Installed? (choose one) ❑
,
PARCEL INFORMATION:
Topography Flat Rolling El Steep Slope % Slope
Soil Nature [Sand ❑ Loam ❑ Clay ❑ Other, explain:
Groundwater At what depth? J,4
Bedrock/Impervious material At hat depth? /) A
Domestic Water Supply RV 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)
PROPOSED SYSTEM INFORMATION:
Tank size ja gallons (min. size 1,000 gallons, add 250 gallons for each garbage cylinder or
spa/hot tub )( 15T1))c,
System Absorption field w/#2 stone Total length a5U ft.; Each Trench 5,0 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
i •
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant: 1
Name(s): SI.,1W-\s tvOun71v9
Mailing Address, C/S/Z: 3 5- kOZ9�-06 ea
Cell Phone: 5'8 3( 1 v q 4 Land Line: iq''J 8 36
Email: 6f \141),S TukiCtfb i a)t
• Primary Owner(s):
Name(s): Y l..7 \ )6J(ca
Mailing Address, C/S/Z: 3o W mite_l -- I
Cell Phone: I g ) 48 0 Land Line:
Email:
❑ Check if all work will be performed by property owner only
• Contractor:Contact Name(s): O c.pa,`
Contractor Trade: ``
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: P9:1)\\C�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 QE d S 14)
SIGNATURE: /U DATE: 1 J J )abta(1,
Septic Application Revised July 2022
•
•
F QUEENSBURY "�'
��'.R 742 Bay Road, Queettsbury,NY. 12804.5902 • •
Septic System Checklist •
•
ilkp Plantoscale .
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)
1 All wells on property and adjacent properties shown .
1.6Water line shown Municipal or well 10'separation to any part of system .
•'f// y •
I etback to property lines show 10'or more for any part of system •
1
epticta k and pump stations 10'from foundation.50'from any well/lake/wetland 10'from any waterline
kris 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)
-fiC3
Septic tank sized for number of bedrooms and add 250 gals for Jacuzzi tubs/garbage grinder each •
`r Leech Field 20'from foundation 100'from any well 10'from water line
I'"I`k Seepage pit 150'from well 50'from septic tank •
j1seepage Pits 3-times diameter apart
-eptic to 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 •
Leech field 100'from watercourse or wetland
Al°k Toe of mound or bottom of retaining wali.l0'from property line 100'from well 20'from •
Foundation
Provide'Engineer/Architect stamp for bed or design systems
•
`PIA'Department of Health Approval for all mobile home park new systems Flood Plain requirements
• ,k. 2'above established flood elevation to bottom of system
1 "'''All tanks anchored or 2'above flood elevation
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JAN 16 2024 ' _,)f COPY
TowN ; (=�;_:LE_r f t- '—
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TOWN OF QUEE�ISSUR'(_._._.-- -- 1
BUILDING & C ES D Te ' r
x Reviewed S a
�- Date:
1
SiiTOWN OF i ?
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j 1 Y .
BUILDING DEPARTMURI�
Based on our limited examination ENT{ z
with our comments ,cqm t w
fuldicating fhe plans an °t be cons�rue�anas~_ �. �_. i S
nfeWcompiiance with the pecifications are in `
- Yorrc Stafe. Building Codes of E
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302.17-1-24 SEP-0033-2024
Shannon Tucker
30 Wintergreen Road 17)
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Residential Septic Alt.