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historical �rurtc o 01letrAtly APPLICATION FOR SEPTIC DISPOSAL PERMIT DATE ,e 2' /la LOCATION OF PROPERTY FOR INSTALLATION � Vim, - p) Owner's Name: k 0 \ \ \J\u v- Telephone: "3.� "'p'+ ll j Address: k C��x � �l ��\\% \c a Cr`ti,.`i cZc�� S \ "c. Installer's Name:R,.b eq ,i 9? \ \\ Ct ,Z Telephone: 7 Number of bedrooms (residential only) ') Total daily flow (compute @ 150 gal per bedroom) q 0 Topography: circle one: 671 Rolling Steep Slope % of slope Soil Nature: circle one: and j Loam Clay Other / Depth: _ feet Ground Water: At what depth? i &T feet Bedrock or Impervious Material: At what depth? _ feet Percolation test: circle one: n required lrequired / rate min. inch. Domestic water supply: circle one: Municipal Well Other IF domestic water supply is a Well: Separation: Watersupply from Septic absorption _( c, cm feet PROPOSED SYSTEM: Septic Tank ( Q cQ gal. (minimum size: 1,000 gal.) TILE FIELD: Each Trench © feet / Total system length p Q feet SEEPAGE PIT(S): Number of / Size each feet by feet Size of stone to be used # / Depth or Thickness _ l feet * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * IMPORTANT ...Please...LIST NEW EQUIPMENT TO BE INSTALLED * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * (over) Section II Septic System Inspections: A. All applications for septic system installation, alteration or repair, as required by the Town of Queensbury Sanitary Sewage Ordinance, shall be submitted to the Building Department at least 24 hours before start of construction and shall include a plot plan showing: 1.) the proposed location of the system 2.) location and distance to lot lines 3.) location and distance to structures 4.) location and distance to any water supply 5.) size and dimensions of all tanks, distribution boxes, tile fields and/or drywells B. No system shall be covered before inspection and approval by the building Inspector. Failure to comply with this requirement may result in the uncovering of the system by the installer and a fine of up to $250.00. C. An approved copy of the plot plan shall be available on the construction site. Failure to produce said plot plan at time of inspection may result in an immediate work stoppage. D. Should unforeseen problems during construction prevent proper installation, alteration or repair of an approved system, a new proposal must be submitted to the Queensbury Building Department before further construction. I have read the regulations above and agree to abide by these and all requirements of the Town of Queensbury Sanitary Sewage Disposal Ordinance. Signature of responsible person: \� Date: [ - 1 ;? Town of Queensbury Building and Code Department Bay at Haviland Road Queensbury, New York 12801 (518) 792-5832 SETTLED 1763 . . . HOME OF NATURAL BEAUTY . . . A GOOD PLACE TO LIVE