application SEPTIC DISPOSAL PERMIT APPLICATION Office Use Only
742 Bay Road,Queensbury,NY 12804
,z„ < ,>h,„ p:518-761-8256 www.gueensbury.net Permit#: �20�'�
Tax Map ID#: „�-a_3 4 o o d3 W • Permit Fee: $ J'0• ; Invoice#: 22'58
Project Location: / s' n !.�`f Septic Variance? Yes No
Primary Owner(s) k' a r,' J ' eon n I`. M 1- *- ,P 46'M-
Mailing Address
6'M-MailingAddress e r aJ4 h. y [a �r(IS"
Phone & Email IS - 8.5_4 -45-3 1 et/iam ikf4 '/.'C•7n
Installer/Builder C A t-J L t-a h o'/ /
Mailing Address G, 3 k/o-e /,L4 c- "i' 1 1
Phone & Email 7 y3 1
Engineer G t--r C_ t- /K
Mailing Address P p t3 6 .S 4 S t-a U S-t- I 3a / 7
Phone & Email 3 1 S- .5 - 'q 9 '• w w td, o ►1 s I (F--..e 7� h e e r,`n ,
(ov s-
Contact Person for Building&Code Compliance: .-s t-COU A Lg h R rn Phone: _�t 9 3'S4- `/53 i
RESIDENCE INFORMATION:
Year Built #of bedrooms X gallons per bedroom =total daily flow Garbage Grinder Yes No
3 Installed? (circle one) �
1980 or older
1981-1991 Spa or Hot Tub Yes No
Installed? (circle one) k
1992-Present
PARCEL INFORMATION:
Topography Flat Rolling Steep Slope g %Slope
Soil Nature Sand Loam Clay Other, /
Groundwater At what depth? 6
Bedrock/Impervious material At what depth?
Domestic Water Supplylok-e _Municipal _Well (if well, water supply from any septic system absorption is_ft.)
Percolation Test Rate: S" per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION: CAU*_
Tank size I 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 &associated electrical work must be in n c rical inspection
agency; 2.We will no longer allow systems to be covered until s c r a n I la a ved and approved.
The installed system must match the septic layout on file—no e o
a161.2017
Declaration:Any permit or approval granted which is based upo rin reance u n material
representation or failure to make a material fact or circumstance o UR&ppll ant, shall be void. I
have read the regulations and agree to abide by these and all req ire rg ^ een s ury Sanitary Sewage
Disposal Ordinance.8
�7
PRINT NAME: v4& DATE: V V
SIGNATURE: DATE:
Town of Queensbury Building&Code Enforcement Revised ebruary 2017