application SEPTIC DISPOSAL PERvITT PPUC TIO r joffi,c Use Only
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Town oftjueenshuxy( P:518-761-8256 www.que@n4• r .net Ilerh t#: JC D ( 1 7`- Za ( �c
Tax Map ID#: 289.10-1-32 APR 1 8 2018 t Fee:$ 7c- 00; Invoice#: rJ 2-
Project Location: 10 HEMLOCKRD,GLEN LAKE I OWN OF QUEEN S IleP.epti4Variance? Yes No
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Primary Owner(s) CAROL BODETTE
Mailing Address 10 HEMLOCK ROAD,LAKE GEORGE,NY 12845
Phone & Email
Installer/Builder GEORGE WOLFE
Mailing Address
Phone & Email 518.307.0026
Engineer HUTCHINS ENGINEERING
Mailing Address 169 HAVILAND ROAD,QUEENSBURYNY 12804
Phone & Email (518)745-0307/THUTCHINS@HUTCHINSENGINEERING.COM
Contact Person for Building&Code Compliance: INSTALLER Phone: (518)307-0026
RESIDENCE INFORMATION:
Year Built #of bedrooms X gallons per bedroom =total daily flow Garbage Grinder Yes No
1980 or older Installed? (circle one)
1981-1991 Spa or Hot Tub Yes No
Installed? (circle one)
1992-Present 3 110 330
PARCEL INFORMATION:
Topography ✓ Flat Rolling Steep Slope %Slope
Soil Nature ✓ Sand Loam Clay Other
Groundwater At what depth? >52"
Bedrock/Impervious material At what depth? >100
Domestic Water Supply _Municipal /Well(if well,water supply from any septic system absorption is ft.)
Percolation Test Rate: 3:10 per minute per inch(test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size 1,000 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: PRESBY ABSORPTION TRENCHES(78 LF)
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. 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: ✓eih Gv DATE:
SIGNATURE:
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Town of Queensbury Building&Code Enforcement Revised February 2017