application SEPTIC DISPOSAL PERMIT APP Air. o�. g 0 to `3€ "0-4. (1--2C't
742 Bay Road,Queensbury,NY 12804 ! " "' — 0( e
Town ofQecns.ury i ��
�tP::518-761-8256 www.queensburv.net �� DEC # . 6� Z
Tax Map ID#: ig . 0 " ...'5 +.'. --:$ 3-7 Invoice#: /1 3
TOWN OF �' EENSBURY
Project Location: J 5 a i BUILDI`�* 45Dt t6ance? Yes No
Primary Owner(s) rA t tify9,ri
Mailing Address PO Bag 45150
Phone & Email "' - 1 - 454 r / lAturti . Yttete314 ets- ' - . .1/ #p. . . .
Installer/Builder
Mailing Address 4°5 W i ►IP e , LAY4. 1/, - r t )2.B -
Phone & Email 51413-14b _6 -
Engineer
Mailing Address
Phone & Email
Contact Person for Building&Code Compliance: &- ` -`` =fit Phone: t 'T 14 41
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)
81-1g1 130 Spa or Hot Tub Yes No.
4-0 12.E
`�.,.,...�,....�...J - Installed? (circle one)
1992-Present 110
PARCEL INFORMATION:
Topography X 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 _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 - u 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 4:.
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: !' l e-') Lei ? S L/ t.) DATE:
SIGNATURE: — DATE: hff*--
Town of Queensbury Building&Code En rcement Revised March 2018