application 4. "< I SEPTIC DISPOSAL PERMIT APPLICATION Office Use_ Only Igt6`
�. • 742 Bay Road,Queensbury,NY 12804 ""_ „ ZD c C
loin)ofC�accn-sburz I' 1 , P mi $•f 7 — — —P:518-761-8256 www.queensbury.net
IlqTax Map ID#: I i „A„ e it Fe' :$ Invoice#. f'j `(
Project Location: )I i n n f 01, Septic #arianc ? Yes No
{ TOWN OF QUEEN$BUF t
Primary Owner(s)
Dove s r VJ c 1C f BUILDING&CODES
Mailing Address 9 5 ;\ mom Pd,
Phone & Email 51 —1 -1 Koc\
Installer/Builder I KS S ep q L
Mailing Address0---I-0w er Worre, 51 , 3\0
Phone & Email S )c -19% -- Vi i
Engineer `ilkArN 1
Mailing Address A 1)1 �� A B3
Phone & Email CI Y r""7 CI,I,.} (
Contact Person for Building&Code Compliance: C\rf t ii Phone: 5 if-7 9- 5I9
RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms X gallons per =total daily flow
per day bedroom Garbage Grinder Yes N:317
1980 or older 150 Installed? (circle one)
1981-1991 130 Spa or Hot Tub Yes No
Installed? (circle one)
1992-Present 110 ( 1 () .)3n
PARCEL INFORMATION:
Topography Fief Rolling Steep Slope %Slope
Soil Nature u "Sand Loam Clay Other
Groundwater At what epth?
Bedrock/Impervious material At w depth?
Domestic Water Supply unicipal _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 LC)fln 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: I, i\ ,o-z"\
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: C Ckrk 4A-IM kY (A DATE: !,` -14-
SIGNATURE: DATE:
r- (Y "-f9-
Town of Queensbury Building&Code Enfor t Revised March 2018