application •
f, Office Use Onl
zik' SEPTIC DISPOSAL PERMIT APPLICATION Permit L: $ �Jl�
Permit Fee: $ , Invoice#: 1-1
Septic Variance? e0 Yes No
low-n of(Zircen.shnrp
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net
TaxMaplD#: 21-1- ��" _ 2-"1 `c,
Project Location: lip c ,.liny ide A , Rd. 4)ueensburY , `J Y
• Applicant:
Name(s): Ieen Fyyl(41
Mailing Address, C/S/Z: tq kyiog4cn arcUc.� Sp(W 5,:Airid o
Cell Phone: _(51V ) `3'7c1 32111 Land Line: _ S1S' ) ' 1 4512.3
Email: c ce_5 75( Vu v uLcc,,'il
• Primary Owner(s): E C EE OLL W E rl
ii
Name(s): �jC vi,e - ,1" 1 APR 2 n 2619 lJ
Mailing Address, C/S/Z: !, i 1
Cell Phone: _( ) Land Line: _( -, `f= -6is� U-E:`` iEURY i
Email: BLOL.ONG& CODES
❑ Check if all work will be performed by homeowner only
• Contractor: Workers' Comp documentation must be submitted with this application
Contact Name(s): 3lone_ L►bkI9c1-io— ) L.-LC'-
Contractor Trade: Jc p)'fe . 'y c.—
Mailing Address, C/S/Z: 4 3i)5 -pad, 5Q 50,,,thr ► , /UV eO r�
Cell Phone:
_(3-2 6 ) 23 2 4 4 707 Land Line: _( ►s. ) S Vy ->I) ��
Email: C e .., c% ,b--' y e—,a aa, iL `47-ems. ‘ , 6-6ane)
• Engineer(s):
Name(s): ), ao 14,
Mailing Address, C/S/Z: ,JhY". , /e. g. 1.1 S , q;V 1Z 1
Cell Phone: _( ) Lan Line: _(57 ) 7 /-- 0 2C8
Email: ai>in 0, e____, 0 7 e.., , re. c,.,-,
Contact Person for Building & Code Compliance: ) — , t-06 14ee, '6t0e_ 14,5,T nc '0
Cell Phone: L,571 ) Z.3'2 07 Land me: (5 h ) S 3V---1O R
Email: d C v1 6 ,oe %vi el ,� r i° , c o,r,..--,
Septic Application Reviceri Fahruary 7(l19
RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms: X gallons per =total daily flow
per day bedroom Garbage Grinder Yes C'q
1980 or older 150 330 Installed? (circle one)
1981-1991 130 Spa or Hot Tub Yes
Installed? (circle one)
1992-Present 110
PARCEL INFORMATION:
Topography ,? flat Rolling Steep Slope %Slope
Soil Naturend Loam Clay Other(explain:
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: 2 5 per minute per inch (test to be complete by licensed engineer/architect)
1)14
(XL/ /geri-
PROPOSED SYSTEM FOR NEW CONSTRUCTION: if/
Tank size /51Ogallons(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: 'Z F/® c.✓
Holding Tank System Total required capacity? ; tank size ;#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 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: ce aa' sae e DATE: Z
SIGNATURE: DATE: fze-i 7
Contir Annliratinn Revicarl Fehn iary?f11 Q