application Office Use Only o0
Permit#: jZ — O j 7 SEPTIC DISPOS Pl T�
Permit Fee:$ 7 UO , Invoice#: j aS_3
l
2
FEB 2019 Septic Variance? Yes No
'run nt(Lx nsbur jl
742 Bay Road,Queensbury,NY 12804 14!
P:518-761-8256 www.queensbury.net
TOWN OF OUEENSBURY
BUI I i G may `'i s
Tax Map ID#: 22 7. / G� " G uN
Project Location: L�fiv<S/ ,q i1
• Applicant: ..//
Name(s): �os?r0.r ,'v ,'C
Mailing Address, C/S/Z: //o A?
Cell Phone: 4S/6e ) ( - MD\t-` Land Line: _(..5/F3 ) It(/-c \ Z 22
Email: 1 �C C i�rfrig4.r',h y e.' oY9�A Rv"te)er * C.0 N'1
• Primary Owner(s):
Name(s): CS14.1 Kul)r ;Grp 1
Mailing Address, C/S/Z: 1164 route- °� , Gy4P%SeVooc' "t.) y 128.$
Cell Phone: ,15/67 ) ~•61..A o Land Line: _( )
Email: t C Ana ; oy9� t�yy1r�e( . C,0 .
❑ Check if all work will be performed by homeowner only
• Contractor: Workers' Comp documentation must be submitted with this application
Contact Name(s): t. o vrti KvbC;GvC� Cowl rq h y yh
Contractor Trade: - e44 /�1 ‘ 1.,WN W -ce. ( 1 Mailing Address, C/S/Z:
Cell Phone: 4.57 e ) ..(l A-lp Al Land Line: _L5 8 ) e )-o
Email:
• Engineer(s):
Name(s):
Mailing Address, C/S/Z:
Cell Phone:_( ) Land Line: _(
Email:
Contact Person for Building & Code Compliance v►-) \<Vbe
Cell Phone: ,1.57 ) 6/,410\ Land Line: (576" ) P1ZZ,
Email: _ E'1)7(Y1e-ec:'y) 1) S.vkir)
Septic Application Revised February 2019
RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms: X gallons per =total daily flow
per day bedroom Garbage Grinder No
1980 or older 150
1 c - 1 Installed? (circle one)
`�0 /5v 1981-1991 130 a
Spa or Hot Tub Yes
Installed? (circle one)
1992-Present 110
PARCEL INFORMATION:
Topography ,C Flat Rolling Steep Slope %Slope
Soil Nature 7C, Sand —Loam i Clay !Other(explain:
Groundwater At what depth?
Bedrock/Impervious material At what depth? q
Domestic Water Supply Municipal 6.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: C rh tee'. bus' 3S , I Z$-0 y a//044
Tank size 12S0 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:
Holding Tank System Total required capacity? ;tank size /25 0 ;#of tanks 3
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 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: ✓' 111 )17 (+. L DATE: e Z1 1
SIGNATURE: DATE: Z/ 0/
Septic Application Revised February 2019