application Office Use Only
licitSEPTIC DISPOSAL PERMIT APPLICATION Permit#: P-0 bob - Zo tel
Permit Fee: $ 15 ; Invoice#: I°- 4
Septic Variance? Yes No
Irnrn of(Lccnchun
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensburv.net
Tax Map ID#: -2i6', 9/ 7/
Project Location: 37/ /A/4-6!/a04/ ✓J/ o 2.S,4T Z*?11'C7/
• Applicant:
Name(s): r2Y2/ $ e,j Al/�%1�_jelt/�
Mailing Address, C/S/Z: ' erdoi/je/ i6r/- wr✓/, 3/,4Z AX
Cell Phone: ( :S 9' ) _2.2 ' 6'6'' Land Line: _( )
Email: yt/iAvvi16 ,,e)r //e07/
• Primary Owner(s): ,�1
Name(s): /S 9A' /U/7
Mailing Address, C/S/Z: o27// Mr* e///he���i /�D 44.,,ties-75----.2:2�
Cell Phone: _( _ 5) ,-,233�.?1y Land Line: _( )
Email: ,/114/, Vcil /'l4.nv<<avri
❑ Check if all work will be performed by homeowner only
• Contractor: Workers' Comp documentation mist be submitted with this application
Contact Name(s): �i'c'rf!'Pn��ri›:/.5' A4AV over-
Contractor Trade: ,.c4Xl'64,,*v� 6Per./1004er
Mailing Address, C/S/Z: .Perof'''�'✓t ,// ,e'4-5/iv4P'q ✓lam/ /242,
Cell Phone: _( 5 6 ) .. 23"66/d Land Line: _( 4?9,1 )
Email:jt/iAV ),,it Pi/,e0,4
• Engineer(s): �0944,�- 4
Name(s): 6., /?4- vc'. 'l' ''ff//
Mailing Address, C/S/Z: /7 h4 r,4" .Se4.0 �''S 1� 5 /r// /,;2�4,
Cell Phone: _( S/, ) �f'/5^97e, Land Line: _(/,S"�8' ) 71�-'3 f
Email:,�ji '4'f/A'2c' - 4� . l� �`
D
_ SEP092019 J
Contact Person for Building & Code Compliance: 1¢07��4‘ef
Cell Phone: ( 51i )2.2.366/O Land Line: ( ) TOWN OF QUEENSBURY
BUILDING&CODES
Email: iii."4 "were/ V ea•- --
Sentir Annliratinn
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 �Vg
Installed? (circle one)
1992-Present 110 #0 4/ %
PARCEL INFORMATION:
Topography jC Flat Rolling Steep Slope %Slope
Soil Nature )(Sand Loam Clay Other(explain:
Groundwater At what depth? ,4/o/7. , s .'r ‘'
Bedrock/Impervious material At what depth? 42 7e ,6m/r0(44 6'
Domestic Water Supply )(Municipal _Well (if well,water supply from any septic system absorption is ft.)
Percolation Test Rate;,20 per minute per inch (test to be completed by licensed engineer/architect)
sec-
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size f S?7 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 y ft.; Each Trench ....5-7=2 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: / 11114 DATE: s / 9
•
SIGNATURE: DATE:
Septic Application Revised February 2019