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application ' SEPTIC DISPOSAL PERMI f'f8 iP IeAT ' is Use Only 742 Bay Road,Queensbury,NY 2 p fa F01177�-,t ceu-�,ur3- APR 1 8 2 I :ITO'° - C0 2.( _ Q 7 P:518-761-8256 www. ueensb 0 eL �Tax Map ID#• 3GT, 7 _ !- r LLv :y' �{ ' _ mit Fee: $ 7 , Invoice#: C ti 3 i .4 ov,;si r: .ict N BURY 1 1 , Project Location: 3 z�T�� -�� -`=�` �� `:� `: `"n` Septi,cvariance? Yes No Primary Owner(s) Mailing Address 0�`J err ! b ever,rVN �--� A Pp-e Phone & Email I" �__ 9i J-IS 6 () Installer/Builder TB S 5 eoi i C 1 Mailing Address #1 L©i ?q( orrr 5 c*, CA Af-Pni-ibUT Phone & Email �j 1/4 -� 1 �- 9 C �� , i bS s?p-H = corya Engineer -To, (._,,,,,,A-c1r Mailing Address 13 5 r i do oa S-1-. 6 lees 5-16, 15 5 -1 96--2SJ Phone & Email [� Contact Person for Building&Code Compliance: (jr f'\ N\,\ Phone:5 l B6( 1 1 l� RESIDENCE INFORMATION: V Year Built Gallons #of bedrooms X gallons per =total daily flow per day bedroom Garbage Grinder Yes No 1980 or older 150 Installed? (circle one) 1981-1991 130 Spa or Hot Tub Yes No Installed? (circle one) 1992-Present 110 `I i I n � n PARCEL INFORMATION: 1 Topography at Rolling Steep Slope %Slope Soil Nature Sand Loam Clay Other Groundwater At w at depth? Bedrock/Impervious material At hat depth? Domestic Water Supply s___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 SYSJEM FOR NEW CONSTRUCTION: Tank size £lc1 t^, gallons(min. size 1,000 gallons, add 250 gallons for each garbage cylinder or spa/hot tub Systemi 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: -)-() >C-i()N 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: L-- t) DATE: Lk I j 2- 1 Lf_i n ,,, Ie.(' SIGNATURE: / DATE: Town of Queensbury Building&Code Enfo cement Revised March 2018