applications Office Use Only
lit SEPTIC DISPOSAL PERMIT APPLICATION Permit#: 3• Zpi�
Permit Fee: $ ; Invoice#:
To �,rcLe��..n�R• Septic Variance? Yes No
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net
Tax Map ID#: 2'9 2'"/'5/
Project Location: %% /C /e'cn %
• Applicant:
Name(s): .9-71-r'"G4 „_ tGj L
Mailing Address, C/S/Z: i'Feg-,-der, 7Zc7
Cell Phone: _(S//' ) Z22 de)6/ Land Line: ( S/, ) _75'S /8'7
Email: -7`f//-/,-.) cif/7 s &,.P0.41/• eer►1
• PrimaryQwner(s):
Name(s): / 1--�it.4, 4' t Jlt ri
Mailing Address, C/S/Z: 22 I o-r-ob- 1 gd
79� /��
Cell Phone: _( SJ6 ) 22? 4,/ Land Line: ( rS/f' )
Email: ;4-ram 6 £ /y P 7.7 s, A C ,-1
❑ Check if all work will be performed by homeowner only
• Contractor: Workers' Comp documentation mu t be submitted with this application
Contact Name(s): /V `'G'// /L 'x c,9 v /i h cj , ,c-1 /v e 6i r a
Contractor Trade: A 444 et Ex«0?-21r in,'
Mailing Address, C/S/Z:
Cell Phone: _071 ) 76— /73O Land Line: (s7$ ) 79.4 /7j
Email: mcy c, yt r'xCoOf-berii @ y,-Acz. CC"?
• Engineer(s):
Name(s): jrt1 11 4 ca42
Mailing Address, C/S/Z: $t Co7,sa L'°'n t e/ /- A- 7 , eY /ZB/ 7
Cell Phone: _( ) Land Line: _( SZ ) r99 ZSSS'
Email: b came) eh ; y •-Pre n iq /r t.l. 4174
Contact Person for Building & Code Compliance:
Cell Phone: _( ) Land Line: p OCT 01 2019
Email:
TOWN OF QUEENSBURY
BUILDING&CODES
Septic Application Revised February 2019
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
PARCEL INFORMATION:
Topography Flat Rolling Steep Slope %Slope
Soil Nature _Sand _Loam Clay Other(explain:
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 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: DATE:
SIGNATURE: DATE:
Septic Application Revised February 2019