application Office Use Only
SEPTIC DISPOSAL PERMIT APPLICATION Permit#: -OO - ZonS
Permit Fee: $ ; Invoice#: aiS
Town ofQueensbnry Septic Variance? Yes 4--- No
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net
Tax Map ID#: 2P-c • l5— 1 • 23
Project Location: 17 OZUi2` 4
• Applicant: -rim/ /)') eaype -z7G
Mailing Address, C/S/Z: /7 azet Ire Ark . etteenskani n y /..)P0t)
Cell Phone: _(5/1 ) 3a/- riko2.d Land Line: _( )
Email: —17)f'1m y(1. (19 0 /Gaud, Ga0
• Primary Owner(s):
Name(s): .--Pk dipe91,41''_
Mailing Address, C/S/Z: /7 aZu. e / le QI.L eel S4Gc.ki h /21P6(.-/
Cell Phone: _( 5`( ) 8a/ - '71.J U Land Line: ( )
Email: -TlhnInc/etti74 v ci) /G�OL�.Ga1,
❑ Check if all work will be performed by homeowner only
• Contractor: Workers' Comp documentation must be submitted with this application
Contact Name(s): 'i cL rm (61,(/rc
Contractor Trade: Ev ea,v4ir kt,4 /�
Mailing Address, C/S/Z: b e A vn',//)1 au AV Fiki-ai 1,i VI y /d fob 7
Cell Phone: _( 5) ,l) Z'6 1150 Land Line: _( 5) cS' ) --me - SY,0
Email: T(40.411 Pica. vetf/n� (0 /4J 0 , /774h--)
• Engineer(s):
Name(s): x,y,.IVT,a,`
Mailing Address, C/S/Z: '"' ------
Cell Phone: _( ) Land i 4 c E)G 4
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Email: ft [ JUN 2 8 2019
ITOWN OF CUEENSBuRY
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Contact Person for Building & Code Compliance: yV ".- —
Cell Phone: ( ) Land Lind: ( )
Email:
Septic Application Revised February 2019
RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms: X gallons per =total daily flow
per day bedroom Garbage Grinder Yes
1980 or older 150 3 1 rD0 4°DO Installed? (circle one)
1981-1991 130 Spa or Hot Tub Yes No
Installed? (circle one)
1992-Present 110
PARCEL INFORMATION:
Topography Flat Rolling Steep Slope %Slope
Soil Nature Sand _Loam _Clay _Other(explain:
Groundwater At what depth?
Bedrock/Impervious material At what depth?
Domestic Water Supply _Municipal _Well (if well,water supply from any septic system absorption is ft.)
Percolation Test Rate: per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size gallons (min. size 1,000 gallons, add 250 gallons for each garbage cylinder or spa/hot tub
System Absorption field with#2 stone Total length ft.; Each Trench ft.
Seepage Pit with#3 stone How many: ;Size:
Alternative System Bed or other type:
Holding Tank System Total required capacity? ;tank size ;#of tanks
NOTES: 1. Alarm system and associated electrical work must be inspected by a Town approved electrical inspection
agency; 2. We will no longer allow systems to be covered until such time as an as-built plan is received and
approved. The installed system must match the septic layout on file—no exceptions. 3. As-built drawings must be
submitted prior to the inspection, if there has been a change to the submitted plans.
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: (Pe 41t/ DATE:
SIGNATURE: 0! DATE: 6 ��
Septic Application Revised Febrjary 2019