application �;i
SEPTIC DISPOSA P ►Ali -F Ito Office Use Only
742 Bay Road,Queensb, NY 12804 //�� _
To olQuccnsbun P:518-761-8256 wwwlqu-e .rie0 al1,1 to 1 Permit#: j - O'7 %L)
Tax Map ID#: 279.12-' Permit Fee: $7 .00; Invoice#: III G
)
i• OF OUELINSDURY
Project Location: 114 gnPyQ11) .4 `CODES i Septic Variance? Yes No
Primary Owner(s) Ronald&Joyce Egnaczyk
Mailing Address 114 Sunnyside North Queensbury,NY 12804
Phone & Email (518) 281-7042
Installer/Builder
Mailing Address
Phone & Email
Engineer Hutchins Engineering
Mailing Address 169 Haviland Road Queensbury,NY 12804
Phone & Email 518-745-0307 thutchins@hutchinsengineering.com
Contact Person for Building&Code Compliance: Hutchins Engineering Phone: 518-745-0307
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 2 110 220
PARCEL INFORMATION:
Topography ✓ Flat Rolling Steep Slope %Slope
Soil Nature ✓ Sand Loam Clay Other
Groundwater At what depth? Greater than 52"
Bedrock/Impervious material At what depth? Greater than 52"
Domestic Water Supply LAKE _Municipal _Well (if well,water supply from any septic system absorption is ft.)
Percolation Test Rate: 4:35 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: 12x20 pipe-in-stone absorption bed
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: ' ( AS 1cfit/V 5 v I DATE: ' �� U
SIGNATURE: St:CL
44.../
_ r
Town of nsbury Building&Code Enforcement Revised March 2018