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application SEPTIC DISPOSAL PERMIT APPLICATION Office Use Only 742 Bay Road,Queensbury,NY 12804 D_ Q of Qi ccw.bur? '\ 0 - P:518-761-8256 www.queensbury.net Permit it ��� Tax Map ID#: 295.19-2-43 Permit Fee:$ II talc ; Invoice#: Project Location: 20 OWEN AVENUE Septic Variance? Yes No Primary Owner(s) CARL BAKER Mailing Address 20 OWEN AVENUE,QUEENBBURY NY n (� 2 0 Phone & Email U l (� E Installer/Builder SANITARY SEWER SERVICES AUG 29 2019 Mailing Address LUZERNE ROAD,QUEENSBURY NY Phone & Email 5187963760 TOWN OF QUEENS$ BUILDING A . ODE Y Engineer TOM CENTER Mailing Address 73 SHERIDAN STREET,GLENS FALLS,NY 12801 Phone & Email TCENTER36@YAHOO.COM Contact Person for Building&Code Compliance: GEORGE DRELLOS Phone: 5187963760 RESIDENCE INFORMATION: Year Built #of bedrooms X gallons per bedroom =total daily flow Garbage Grinder Yes No 1980 or older Installed? (circle one) 1981-1991 Spa or Hot Tub Yes ©o Installed? (circle one) 1992-Present 3 110 330 PARCEL INFORMATION: Topography • ✓ Flat Rolling Steep Slope %Slope Soil Nature Sand Loam Clay Other Groundwater At what depth? DEEPER THAN 6' Bedrock/Impervious material At what depth? NONE Domestic Water Supply j Municipal _Well (if well, water supply from any septic system absorption is_ft.) Percolation Test Rate: 1'-5' per minute per inch (test to be completed by licensed engineer/architect) PROPOSED SYSTEM FOR NEW CONSTRUCTION: Tank size 1000 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: 20 X 25 FT BED 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 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: e DATE: 2 SIGNATURE: ' Town of Queensbury Building&Code Enforcement Revised February 2017