8917 TOWN OF QUEFNSBURY
BUILDING & ZONING DEPARTMENT TOWN OF QUEENSBURY
SEWAGF DISPOSAL PERMIT APPLICAT � iF - L� E j
1. Owner ' s Name cktrzAT'11h 00 of- G z,&.°s 44"--6 [JhC 4 1984
A.m. /o, J�
Address ( -cJ 1 A-110.0/�(A-t-L-Av l qra--t 0A) !20 P.Mo
7 8 9 it lg/eta lj 4 b.C
rActS, / 'O/ Telephone No. i '293- / 8
2. 'Property location Aut.isvrt OA) /q,4c4.. - J tNri--10,0 /'o-GsL&vS CA-Lt5,A
3. Name of person or firm responsible for installing system
A- A-8 O(A- Telephone No. 7?3-w/ 8'
Address
4. Number of bedrooms (residential buildings only) .t/jA-
5. Daily flow 3c),000 G AL (Ak-) Co - gallons/day
6. Septic tankScapacity (3) Z 5, 000 - /Z.C>oO - /0000 gallons
7 . Topography: flat, rolling, steep
% of slope rt. i- -
8 . Nature of soil and depth /a,tyb - / g �T-
9. If ground water, bedrock or impervious material is apparent at what
depth does it begin? /l/l,- ft.
10. Percolation test: A is required
B is not required
C If required what is the rate minutes/inch
11. Water supply: municipal, well, other /*),(//e,t)94.,__
12 . 'rype of system proposed: drywell, tile field, other J.Afict/ FL.D
Any contractor, corporation, individual, etc. engaged in the construction
of a sanitary sewage disposal system who covers the same before inspection,
does not have an approved permit, or - ' -s from the approved application
will be subject to a penalty of $ 0 as pro ' • ,?- for in Section 6 . 010 of tl
Queensbury Sanitary Sewage Ordi
1
Date ID t�-c 3/ (Q y,5/
signat e of applicant
On separate sheet of paper submit . - ' - • - of the proposed septic system
with all dimensions, including distance from any structure, distance from
property line and domestic water supply, etc. Include all dimensions of
the system itself .
Form 3-82