application itSEPTIC DISPOSAL PERMIT APPLICATION Office Use Only
742 Bay Road,Queensbury,NY 12804 I C y ^
nH n of Luc n.hun
�JC_,P--OIQQ J - .. 3 kci
P: 518-761-8256 www.queensbury.net G
Permit#:
Tax Map ID#: 2 dal -1. .. — L Permit Fee: $ 5 ; Invoice#: r-M5
Project Location: Vv' 1 Ood tQr Lp,. Septic Variance? Yes No
Primary Owner(s) ila4f c -1- 3(1.3 EtA 5
Mailing Address
Phone & Email L —4�/%,.9�°— �6 `•'�t)0`6 n
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Installer/Builder QPil'
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Mailing Address li-ri, , AW Pr WOff 9f• �i Gv-ersb`ovi�, NN1
Phone & Email J I — 91— . + ilk nn E2
Engineer `_A�W\ PO V
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Mailing Address 1 Lf Di9. G-1-e, - `� H ,
SEP 05 2019
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Phone & Email 1' ='141-�0 Z 6�' J
Contact Person for Building&Code Compliance: C I r T N O V �,
'1� �1L�1 � O
RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms X gallons per =total daily flow
per day bedroom Garbage Grinder Yes
1980 or older 150 Installed? (circle one)
1981-1991 130 Spa or Hot Tub Yes No
` , ` n Installed? (circle one)
1992-Present 110 (1��J
PARCEL INFORMATION:
Topography /lling
Steep Slope %Slope
Soil Nature Loam Clay Other
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 SYS— M FOR NEW CONSTRUCTION:
Tank size ,LSO 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: ; SizQ:
Alternative System Bed or other type: -07„3J
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.
1
PRINT NAME: 11 ri j DATE: 9'— '117
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SIGNATURE: / DATE: 9, s,..A3
Town of Queensbury Building&Code Enforcement Revised March 2018