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application Office Use Only Permit#: 6E ) - D b'6 - 1Al J 4rilitSEPTIC DISPOSAL PERMIT APPLICATION Permit Fee:$ 1rJ" ; Invoice#:fig 4, TowTi nf(Zccnsbury Septic Variance? Yes No 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.queensbury.net Tax Map ID#: p°' , /- - / _ S Z Project Location: O r e s}" c.r ,Z. 117L 2,.� -z/ / ./ ivH ci ! • Applicant: _ Name(s): c.2,-, c / y . 4. / . - 7 C S Mailing Address, C/S/Z: _ G4 ' Cell Phone: _( ,8 ) Z Land Line: _( )_��� --10 S Email: r,c.. (ems �k . :.-r d✓.L . G ors-. • Primary Owner(s): , Name(s): PH? -6,- 1-t, - Mailing Address, C/S/Z: J" $ 7 J -moo,-- e-c,�5 1 .r. J R, N0 t. Cell Phone: _( ) Land Line: _(5) ) `�_ - `7 7 Email: ❑ Check if all work will be performed by homeowner only • Contractor: Workers' C mp documentation mpst lie submitted with this application Contact Name(s): `�- yc. !' c, �F-,c��� Contractor Trade: S�P ,� -�,�,.,_, Mailing Address, C/S/Z: `3o S' f-t, _ c D , _, c',:.74,5 /1/ f a 8 A Cell Phone: _CW8 ) - o Land Line: Email: , S ohr ikid 4r- r�C r: c.)iv1 • Engineer(s): �- > Name(s): kZ e r `I t G�c-i ,c; Mailing Address, C/S/Z: _ZZ eu( , ( r, S i • iK/7g _(d�_) �) 7-o o � Land Line: ( )Cell Phone: �' S Email: 3 Contact Person fo�r Building & Code Compliance: -e ei :� �J1 �AV Cell Phone: ( Z9 ) Z7Z 7o7 Land ine: ( ) Email: DECEpVE ll II AUG 2 7 2019 0 TOWN OF QUEENSBURY Septic Application BUILDING&CODES Revised February2019 RESIDENCE INFORMATION: Year Built Gallons #of bedrooms: X gallons per =total daily flow per day bedroom Garbage Grinder Yes QC' 1980 or older 150 3)( L j ° �ie> 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 /n gallons(min. size 1,000 gallons, add 250 gallons for each garbage cylinder or spa/hot tub System Absorption field Total length 2/© ft.; Each Trench 5-5- 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 Disp al Ordinance. PRINT NAME: / _ re, J DATE: £c ; SIGNATURE: ..� DATE: Septic Application Revised February 2019