application ~ "- SEPTIC DISPOSAL PERMIT APPLICATION Office Use Only a 1,L
- 742 Bay Road,Queensbury,NY 12804 _ -.- Cfqt-"--7 of 7
town ofCtyeensbnn -- -
P:518-761-8256 www.queensbury.n t 1.
.2-`1(.P 1 '-� .n .,p�'� Fe- . 7 `O Invoice#: b .Li.--c.)-2—
Tax
Map ID#: vl
Project Location: 2 ( ' \cc), c +Lcp I1QY Li 8 Niatic te? Yes No
Primary Owner(s) 0 j ;n afTOWN OF(TUEFhSPURY
Mailing Address CODES
Phone & Email I, 6".. ) CP e'.el 01
Installer/Builder 6 ,5 i v L �,,i_ { (Cft -. a
Mailing Address L.
La \/N fl \_AI o rc,,- Lit : w
Phone & Email -111a-cei
Engineereill"dwra HIA
Mailing Address 1 j- Ok Kl:1
Phone & Email
Contact Person for Building&Code Compliance: ri Phone: l 6 I'� �--�
RESIDENCE INFORMATION: 6
Year Built Gallons #of bedrooms X gallons per =total daily flow
per day bedroom Garbage Grinder Yes N
1980 or older 150 Installed? (circle one)
Spa or Hot Tub Yes 019/
1981-1991 130 Installed? (circle one)
1992-Present 110 / 4 rr
PARCEL INFORMATION:
Topography L F t Rolling Steep Slope %Slope
Soil Nature Sand Loam Clay Other
Groundwater At wh depth?
Bedrock/Impervious material At at 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 FOR NEW CONSTRUCTION:
Tank size I'L () 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 ) no 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 ;#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. itYar
PRINT NAME: C 13-0/ t DATE:
i J
�
� p
SIGNATURE: \•••(,q1
\ DATE:
Town of Queensbury Building&Code Enforcement\, Revised March 2018
engineering fees may be necessary per Town of Queensbury Local Law 136-14D.
SIGNATURE OF APPLICANT: Date: /lip
SIGNATURE OF AGENT: / . 5 Qi►'Date: 4 k
Original (B&C File) Canary(Planning) Pink(Applicant) Gold (Town Clerk)