septic submission -i
TECEOV EOffice Use Only( �(pPermit#: ` e i2 '2_0'1
SEPTIC DISPOS U • ' ' Permit Fee:$ • Invoice#: tcr:e
Town of ry
SEP 10 2019 Septic Variance-? Yes No
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net TOWN OF QUEENSBURY
BUILDING& CODES
Tax Map ID#: 2 39 " z
Project Location: b ( ,or ri bra L_
• Applicant:
Name(s): Ckc& c-tro. �5 <<--
Mailing Address, C/S/Z: S� 131a,cL- -, IrZ calse..c' i f, 1') ( I Z$'? I
Cell Phone: ( ) Land Line: _( S'8 ) *q 3 - ZZgr_
Email: ivy L , ,-,:, S) S�►p�:� , c
• Primary Owner(s): /
Name(s): �- �t �� t
Mailing Address, C/S/Z: 6 Mores- br kve
Cell Phone:_( ) Land Line: _( *y S ) 'i g`� - 'in
r)
Email: e yQ ; s'l 26' €
❑ Check if all work will be performed by homeowner only
• Contractor: Workers' Comp documentation must be submitted with this application
Contact Name(s): Morn: '% Shr Se •C
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: _(
Email:
• Engineer(s):
Name(s): E L7 e t.. nvo'd .„ .4A
Mailing Address, C/S/Z: qco / r nv
e
Cell Phone: _( ) Land Line: _(ci ) 3 7 ) — 761
Email:
Contact Person for Building & Code Compliance:
Cell Phone: ( ) Land Line: (
Email:
Septic Application Revised February 2019
A
RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms: X gallons per =total daily flow
per day bedroom Garbage Grinder Yes No
1980 or older 150 Installed? (circle one)
1981-1991 130 Spa or Hot Tub Yes No
Installed? (circle one)
1992-Present 110 //G (�
PARCEL INFORMATION:
Topography Flat Rolling Steep Slope %Slope
Soil Nature Sand Loam _Clay cOther(explain: .1,���
Groundwater At what depth?
Bedrock/Impervious material At what depth? 42•. J
Domestic Water Supply _Municipal JCWell (if well,water supply from any septic system absorption is ft.) LcI
Percolation Test Rate:e e2 per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SY$TEM FOR NEW CONSTRUCTION:
Tank size r"-f.0Agallons (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 (k 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: U : DATE: /A /q
SIGNATURE: DATE: 61/bD//01
Septic Application Revised February 2019