application SEPTIC DISPOSAL PERMIT lice Univ
742 Bay Road,Queensbury, NY 12Togo, 0
n ,f,;:.cZ« ,;;n n P:515-761-5256 www. ueensbar 2i 11C ?:;j�fl '" j
Tax Map ID#: I�, 11 - 1-10 17er i : $ 0V ; invoice#:��?
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Project Location: c Vari nce? Yes No
Primary Owner(s) ;'�,k'c.z 1� ILDING CODES
Mailing Address SlaCUt A 4 aU5
Phone & Email
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Installer/Builder S . -6
Mailing Address �iAAAA �f ,S
Phone & Email -5' 7`7"3—'W 4 e-roserv'CC3-- uoiiwi e .Ccs
Engineer �LOCC"
Mailing Address
Phone & Email ( - , _I'?j• uQ 5 3
Contact Person for Building&Code Compliance: DCV_tFk--C Phone: `3(tj/ '�'L
RESIDENCE INFORMATION:
Year Built #of bedrooms X gallons per bedroom =total daily flow Garbage Grinder Yes No
1980 or older L �� Installed? (circle ane)
1981-1991 Spa or Hot Tub Yes N
Installed? (circle one)
1992-Present
PARCEL INFORMATION:
Topography Flat Rolling Steep Slope %Slope
Soil Nature Sand Loam Clay Other
Groundwater At what depth?
Bedrock/Impervious material At what depth?
Domestic Water Supply _Municipal ' ell (if well, water supply from any septic system absorption is)Q0 ft.)
Percolation Test Rate: per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size JIV50 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 4t7 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. 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: DC�1�-� �- ( 7 DATE: Oldr?
SIGNATURE: 11"Lo
DATE: l 1 11(
Town of Queensbury Building&Code Enforcement Revised February 2017