application .,= SEPTIC DISPOSAL PERMIT APPLICATION Office Use Only eit)�2
742 Bay Road,Queensbury,NY 12804 Ttm'n tof(tu en.,lnin Permit#: c�_ AI
518-761-8256 www.queensbury.net )`- `
Tax Map ID#: Permit Fee: $ 1-5 ; Invoice#: Viitab
Project Location: 3 '7 /\I v-.,11V ' Uf AtSeptic Variance? Yes No
Primary Owner(s) Ke li rr
Mailing Address P , i MA =01
, ,t��ti � y ce
O.111
Phone & Email Y b6 ) c) 4 DI co z O
Installer/Builder I f 3 ? ' a -, 11 ad
Mailing Address ,1( ec. AIofr()��� . G,A..e c,51.) v, Qz
Phone & Email _1 �_�'1 a -�
Engineer `` mgA-.
Mailing Address r'1 r e
i
Phone & Email ( J --i 1OI C
Contact Person for Building&Code Compliance: C t/'1) Phone: t ��3 61' 1 *GI')
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
I Installed? (circle one)
1992-Present 110 ) ItRolIin
PARCEL INFORMATION:
Topographyg Steep Slope %Slope
Soil Nature Sand Loam Clay Other
Groundwater At what depth?
Bedrock/Impervious material At what depth?
Domestic Water Supply _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 FQ It4EW CONSTRUCTION:
Tank size j;A 'alton)s(min. size 1,000 gallons, add 250 gallons for each garbage cylinder or spa/hot tub
System Absorption field with#2 stone Total length �O ft.; Each Trench �i 0 ft.
Seepage Pit with#3 stone How many: ; Size:
Alternative System Bed or other type:
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. r /'
PRINT NAME: U /V:,) Yr DATE: —I -'2-1 I
SIGNATURE: 0 DATE: H.- '1-'-'{
Town of Queensbury Building&Code Enforcement Revised March 2018