Loading...
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