application 03/21/2019 10: 34 FAX 5187610152 Ej001
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Office Use Only
SEPTIC DISPOSAL PERMIT APPLICATION Permit#: SEP 06,13 -.30,1
Permit Fee:$ 15. 00; Invoice#: Mes9
'hum nf(jyKrnsM,ry Septic Variance? Yes No
742 Bay Road,Queensbury,NY 12B04
P:518-761-8156 www.queensburyLaet
Tax Map ID#: s2,3100 3O I . 4 - ( — 5 i g
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Project Location: 18 SVGAR PINE RD G1VEENs8tR\/ SEP f0 20tq �
TOWN OF OUEENSBI
• Applicant: BUILDING& coo
Name(s): Sc.o7T SEV ER A-NG� ........__.... .
Mailing Address, C/S/Z: 18 six-AR p/N? R o AP Q vEE Nag vRy NY 128011
Cell Phone: _( Sl 8 ) 222 -$Oe O Land Line: ^( S 18 ) 761 • 0/52
Email: ,sSty y e rood rt h n e r, c.o rY1
• Primary Owner(s): (iS A M E As AA o vE)
Name(s):
Mailing Address, C/S/Z:
Cell Phone:_( ) Land Line: _( )
Email:
0 Check if all work will be performed by homeowner only
• Contractor: Workers' Comp documentation must be submitted with this application
Contact Name(s): E IIS W ott h d' S c r\ x(:. ,v t?+ i
Contractor Trade: 1.CAV o- 10h
Mailing Address, C/S/Z: 10 30 .- S+"ct-i-e.. Po LCk 1 H
Cell Phone:_( ) Land Line: _( 514 ) -1 4 b-Ci 1'1 b
Email: d\nl- Nn_ Q Q.A\Swarth e_Kce, v0.k lkr\.5) , Lavv`
• Engineer(s):
Name(s):
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: _( ) _
Email:
Contact Person for Building & Code Compliance:17c_rszso, - r.s
Cell Phone: _( ) _ Land Line: ( ) 5vo - 132.. ffi581
Email:
Septic Application Revised February 2019
03/21/2019 10:34 FAX 5187610152 f1002
IECIEOWE ,
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SEP 10 7f!19 l L
TOWN OF QUEENSBIJP`'
BUILDING & CtT ' E
RESIDENCE INFORMATION: �r
Year Built Gallons #of bedrooms: X gallons per =total daily flow
per day bedroom _ Garbage Grinder es No
1980 or older 150 Installed? (circle one)
1981-1991 130 3 Spa or Hot Tub Yes No
Installed? (circle one)
1992-Present 110 PARCEL INFORMATION:
Topography �►_Flat Rollin Steep Slope %Slope
Soil Nature . Sand Loam Clay Other(explain: )
Groundwater At what depth?
Bedrock/Impervlous material At what depth?
Domestic Water Supply AK Municipal _Well(if well, water supply from any septic system absoption Is ft.)
Percolation Test Rate: per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEM 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.
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: SCO7r SEVER4NGE DATE:
SIGNATURE: frvei DATE:
Septic Application Revised February 2019