application 'aSEPTI:C DISPOSAL`°PERMIT APPLICATION Office Use only .
742 Bay Road,Queensbury,NY 12804
Town of Qaccns:un
P:518-761-8256 wiww.queensbury.net Permit c�'
� — 5-C�• 7� il
Tax Map•ID#: Permit Fee:$ 15 ; Invoice#: 1`10 WQ
f--) G-i- D /1� n oc- r�' Septic Varian e Pro ect Location: .. v,
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Primary Owner(s) . ii\Afi,-`.'.V t oQd i on<42R,ii _, 1 _ I
Mailing Address ��.A AUG_ 1 .20i9 ,�
(III fir . 56,, , e _
Phone &'Email -J l �- -3 I L- f V __ 1 ---1
Installer/Builder. 85 BUILDNZ4 8,CODES �Tr1
Mailing Address kAtic ,,,4, Le kon
Phone & Email 5 D ~y .q ::.. . .
Engineer Ir;� U, �- G,
Mailing Address 13 �f D C yvt, . .V- ifnc F01,15 .N�1
�/ --02,4K //
---. Phone.& Email--- .. _ 5.1 Q_"�L.1 I -------- ----- --
Contact Person for Building&Code_Compliance: C �^(' •I Phone: 5 ` 0U:3 0J2 Lf
65-
RESIDENCE INFORMATION:
Year Built . . Gallons. . #of bedrooms X gallons per total daily flow..
Garbage per day bedroom Gr
inder Yes No ' ,
1980 or older 150 Installed?. (circle one) .
.. ( Spa or Hot Tub Yes No
1981-1991 130
Installed? (circle one)
1992-Present 110 . .. ( 13 �LI
PARCEL INFORMATION: I
Topography . lat Rolling Steep Slope %Slope
Soil Nature Sand Loam Clay - Other.
Groundwater. - At at depth?
Bedrock/Impervious material, At hat depth?
Domestic Water Supply Municipal Well (if well,water supply from any septic system-absorption is ft.)
Percolation_Tes ,Rate: per minute per inch(test to be completed by licensed engineer/architect)
PROPOSED S TEM 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.
f Seepage.Pit with#3.stone How many: ;Sze:
Alternative System . Bed or other type:. e.)_S •NA ZO'
Holding Tank System Total required capacity? ;tank size. ;.#of tanks
NOTES: 1.Alarm system &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.
Declaration:Any permitor approval granted which is based upon or is granted in reliance upon any material
representation or failure to make a material factor 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 Ordinanc (n p er I
PRINT NAME: V �.r(1..� k l 0 p f J DATE: ! ,�)
L I
SIGNATURE:, DATE: V....16"—f
4Town of Queensbury Building&Code En ce t. Revised March 2018