application rr
i
n SEPTIC DISPOSAL PERMIT APPLICATION Office Use Only
--__T 742 Bay Road,Queensbury,NY 12804
kern of Qunsbur•t P:518 761 8ZS6
Permit#: c�'P" 0 tji50 - 20t b
Tax Map ID#: Permit Fee: $ S ; Invoice#: DWI-
Project Location: > I OCI-✓L7 C / Septic Vaf ' 'e �~°- .n Y s»• -�� -----•-Ne--t
Primary Owner(s) LL o 7-vr-i/e CI "° `'•"i
`1�
Mailing Address •3 6 4 / 13+erri CT it SEP 11 2018 ,
Phone & Email � j
Installer/Builder 1> LA-,J��- — E>eh .?-j I OWN OF OUEENSBUR I
RUll 8,cac~ '
Mailing Address /G( I :- //I- 4ej,_K_ act il.�. 6 ca re-—77- �-� i
Phone & Email 1 S - '3 6,i 79 -t' - I'`lekr,Peckr7o2 c 1-64/4-;( , c‘,6-‘
Engineer c_ r-y -*'j f) ,c}//
Mailing Address
Phone & Email �1
Contact Person for Building&Code Compliance: '2(0 b Lam"/ Phone: 5 I b -3(p1'.. 7c,1
RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms X gallons per =total daily flow
per day bedroom Garbage Grinder Yes No
1980 or older 150 1 /5- Oats Installed? (circle one) X'
1981-1991 130 Spa or Hot Tub Yes Nq,
Installed? (circle one)
1992-Present 110
PARCEL INFORMATION:
Topography Flat Rolling Steep Slope %Slope
Soil Nature Sand , Loam Clay Other
Groundwater At what depth? / ` '3-j',
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 SYSTEM FOR NEW CONSTRUCTION:
Tank size gallons(min.size 1,000 gallons, add 250 gallons for each garbage cyli der or spa/hot tub
System Absorption field with#2 stone Total length Zio ft.; Each Tren 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 &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.
have read the regulations and agree to abide by these and all requirements of the Town of Queensbury Sanitary Sewage
Disposal Ordinance.
PRINT NAME: k)°+2 LA-4 C DATE: C/_//` /
SIGNATURE: DATE: 1— I (— i
Town of Queensbury Building&Code Enforcement Revised March 2018