applicationSEPTIC Disposal PERMI)ABPLIEAFION
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‘Tax Map ID#:288.|Permit Fee:§75 (0;Invoice #:_2227.OWN OF QUEENSBURY
Project Location:68NORTHWoODDR|___BUILDING &CorfeSentic Variance?__Yes No
Primary Owner(s)__|PHILIPDELORIA :
Mailing Address 68 NORTHWOODS DRIVE,QUEENBSURY NY
Phone &Email
Installer/Builder|SANITARY SEWER SERVICES
Mailing Address LUZERNE ROAD,QUEENSBURY NY
Phone &Email 5187963760
Engineer ‘TOM CENTER
Mailing Address 73 SHERIDAN STREET,GLENS FALLS,NY 12801
Phone &Email ‘TCENTER36@YAHOO.COM
Contact Person for Building &Code Compliance:GEORGE DRELLOS Phone:5187963760
RESIDENCE INFORMATION
Year Built|#ofbedrooms|Xgallons per bedroom_|=total daily flow||Garbage Grinder Yes
1980 or older Installed?(circle one)ater Spa or Hot Tub ves |(®
Installed?(circle one)1992-Present 3 110 330 |
PARCEL INFORMATION:=
Topography 7 Fiat Rolling Steep Slope %Slope
Soil Nature
_v7 Sand Loam Clay Other
Groundwater |At what depth?DEEPER THAN 6°—Bedrock/Impervious material|At what depth?NONE
Domestic Water Supply Municipal __Well (if well,water supply from any septic system absorption is___ft.)
Percolation Test,Rate:1-5"per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tanksize |1000 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:
[___Talternative System Bed or other type:20X25 FT 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
Tepresentation or failure to make a material fact or circumstance known by or on behalf of an applicant,shall be void.|
have read the regulations and agree to abide by these and all requirements of the Town of Queensbury Sanitary Sewage
Disposal OrdinanceCPRINTNAME:Teerae Dee (Bh vate://~2 SAFay<2 Zo
Town of Queensbury Bulding &Code Enforcement Revised February 2017
SIGNATURE: