application # ,
SEPTIC DISPOSAL PERMIT APPLICATION Office Use Only
742 Bay Road,Queensbury,NY 12804 v051 _ rL�t G
Town ofQuccnsbunr Permit#:
P:518-761-8256 www.queensburv.net
Tax Map ID if:240.6-1-32 Permit Fee:$ IcDO ; Invoice#: t212
Project Location: 2464 Ridge Road Septic Variance? _ Yes No
Primary Owner(s) Mike Chrys(Garner Unlimited)
Mailing Address PO Box 341769 Tampa, FL 33694
Phone & Email 518-339-3559
Installer/Builder Chris Crandall D E G E O W
Mailing Address Click or tap here to enter text. 11 FEB p 1 2019
Phone & Email 518-470-4694 - J
Engineer Click or tap here to enter text. TOWN OF QUEENSBURY
Mailing Address Click or tap here to enter text. BUILDING&CODES
Phone & Email Click or tap here to enter text.
Contact Person for Building&Code Compliance:Click or tap here to enter text. Phone:Click or tap here to enter text.
RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms X gallons per =total daily flow
per day bedroom
1980 or older 150 Click or tap here to Click or tap here Click or tap here Garbage Grinder Yes No
enter text. to enter text. to enter text. Installed? 0 0
1981-1991 130 Click or tap here to Click or tap here Click or tap here to Spa or Hot Tub Yes No
enter text. to enter text. enter text. Installed? ❑ ►��
1992-Present 110 5 110 550
PARCEL INFORMATION:
Topography ®Flat Rolling 0 Steep Slope %Slope
Soil Nature ►5 Sand ® Loam ❑ Clay Other
Groundwater At what depth?Click or tap here to enter text.
Bedrock/Impervious material At what depth?Click or tap here to enter text.
Domestic Water Supply ❑ Municipal 0 Well (if well,water supply from any septic system absorption is ioo ft.)
Percolation Test Rate: per minute per inch (test to be completed by licensed engineerjarchitect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size _1500_gallons(min. size 1,000 gallons,add 250 gallons for each garbage cylinder or spa/hot tub
Systern 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: Click or tap here to enter text.
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.
PRINT NAME: r t Ke (,(1 r! _ DATE: 2/ i /i
SIGNATURE: , ,L/1
Town of Queensbury Building&Code Enforcement Revised January 2019