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Office Use Only SEPTIC DISPOSAL P ;� • • Permit#: S�� U53Z -7-4-) 7 �� ;, �� . Permit Fee: $ 7S '� ; Invoice#: n„,, h.,,, Wes, �� Septic •Variance? Yes No 742 Bay Road,Queensbury,NY 12804 I P:518-761-8256 www.queensbury.net q�� p g bps TOWN OF QUfENSBLJRY Tax Map ID#: 289.9-1-29 BUILDING&CODES Project Location: 12 Sullivan Road • Applicant: Name(s): Karl A Brenneisen, Trustee Mailing Address, C/S/Z: 17 Ash Drive Lake George, NY 12845 Cell Phone: ( 518 ) 361-5735 _ Land Line: ( Email: • Primary Owner(s): Name(s): Frank M Brenneisen, Sr Irrevocable Trust Mailing Address, C/S/Z: 12 Sullivan Rd Lake George NY 12845 Cell Phone: _( ) Land Line: _( Email: ❑ Check if all work will be performed by homeowner only • Contractor: Workers' Comp documentation mu t be submitted with this application Contact Name(s): �� Q� ICNC \� Contractor Trade: Mailing Address, C/S/Z: Cell Phone: _( ) Land Line: ( Email: • Engineer(s): Name(s): Hutchins Engineering Mailing Address, C/S/Z: 169 Haviland Road Queensbury, NY 12845 Cell Phone: _( ) Land Line: _( 518 ) 745-0307 Email: thutchins©hutchinsenginerering.com Contact Person for Building & Code Compliance: Karl Brenneisen Cell Phone: ( 518 ) 361-5735 Land Line: ( 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 No 1980 or older 150 2 150 300 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? > 60" Bedrock/Impervious material At what depth? > 60" Domestic Water Supply _Municipal ✓ Well (if well,water supply from any septic system absorption is 101 ft.) Percolation Test Rate: 1:05 per minute per inch (test to be completed by licensed engineer/architect) PROPOSED SYSTEM FOR NEW CONSTRUCTION: Tank size exist 1,000 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 135 ft.; Each Trench 45 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- � Lth.tt-Nt.it.13E t" DATE: J f 1 t\ ems. SIGNATURE: 415/ litiV''QN' DATE: ( if ( Septic Application Revised February 2019