applicationcaseSor
Permi >29 \'SEPTIC DISPOSAL PERMIT APPLICATION Permit Fee:$_#ides
Tow of Ce Septic Variance?Yes No
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net
craxmapio:_202VE-2yWo
Project Location:cDotv aS UY,NY 12P64
*Applicant:
Name(s):___vSho (vo)liga
Mailing Address,C/s/2:2 Arbdbs Dene Queensbury,jr 1 2F07
Cell Phone:_(_S7§_).bs Sri land Line:_()__ala
Email:=+J @ Gmail).Com
¢Primary Owner(s):
Name(s):__Ju Sha Culligan
Mailing Address,C/s/2:_2/e H-byw>“Deve vec Sioa WOT (PP,
Cell Phone:_(SIF_)321 74>Land Line:_()_AEmail:“\Cojhoga 1S Crm!@SeJ
O Check if all work will be performed by homeowner only
*Contractor:Workers’Comp documentation must be submitted with this application
Contact Name(s):_Arc [Vie Gui
Contractor Trade:Cavaring +Truck
Mailing Address,C/s/Z:ST Buideomi Falls (ad Fort fun,WY p22
Cell Phone:_(_3i¥)79b -1730 landline:(318 )_74@-5662.
Email:
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+Engin D VE iName(s):DL soy -+¢-opig HUMailingAddress,C/S/Z:Lt ———-
Cel Phone:_{_)landline:[TOW F cures.|
MelContactPersonforBuilding&Code Compliance:Bi ch IM Me}ikCellPhone:(S 1%)7U4-j730 Landline:(WE)24K.582
Email:,
Septic Application Revised February 2019,
RESIDENCE INFORMATION:
Year Built Gallons|#of bedrooms:|X¢allons per |=total daily flow
per day bedroom Garbage Grinder Yes [ne]
1980 or older|150 D Installed?(circle one)
7981-1991 730 ‘Spa or Hot Tub Yes [no|Installed?(circle one)
1992-Present|110
PARCEL INFORMATION:
Topography Xx Flat Rolling Steep Slope‘%Slope
Soil Nature SZ sand __Loam Clay Other (explain:)
Groundwater ‘at what depth?
Bedrock/Impervious material|At what depth?
Domestic Water Supply 2X 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 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 200 ft;Each Trench _ft 97 esSeepagePitwith#3 stone How many:;Size:
Alternative System Bed or other type:
Holding Tank System Total required capacity?jtanksize5#of tanks
NOTES:1.Alarm system and 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.3.As-built drawings must be
submitted prior to the inspection,if there has been a change to the submitted plans.
Declaration:Any permit or approval granted whichisbaseduponorisgrantedinrelianceuponanymaterial
representation 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 Ordinance.
print NAME:<I U5h gga DATE:ulil
SIGNATURE:Ze /
DATE:uf ul 14
Septic Application Revised February 2019