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application
S4-L-LS TOWN OF QUEENSBURY,=cae APPLICATION FOR SEPTIC DISPOSAL PERMIT.OUS=NSpermit #Yo79FS :Fee Paid cyl Ho Sa fo.Date:heed y LOCATION OF PROPERDS FOR Yi.sene.ai Pl Bb, Owner's Mailing Address:=Neca nu y n °Or Installer's Name:(Wer ws Bury Sewer Phone #:Lid50G Number of bedrooms (if residential):3 Total daily flow (residential-compute @ 150 gal.per bedroom):“A (2 Flat)Rolling Steep Slope of SlopeTopography-Circle One: Soil Nature-Circle One:(Sand)Loam Clay Other /Depth: Ground Water-At What Depth?Feet Bedrock or Impervious Material-At What Depth?Feet Percolation Test-Circle One:WotRequiréd Required/Rate Min.Per Inch Domestic Water Supply-Circle One:‘echmeeipat |Other If domestic water supply is a we Separation:Water supply from any septic absorption “7O_feet “ST PROPOSED SYSTEM:Septic Tank exw gal.(Minimum size:1,000 gal.) Tile Field:Each Trench 470 feet//Total System Length Za ro feet Seepage Pit(s):Number of /Size each:ft.x ft. Size of Stone to be used:#)_/Depth or Thickness “0 ©feet enorHOLDINGTANKSYSTEMIF REQUIRED No.of Tanks Size\of Each Gal. Alarm system and associated electrical work to be inspected by a certified agency.Jenene T have read the regulation on the reverse side of this sheet and agree to abide by these and all requirements of the Town of Queensbury Sanitary Sewage Disposal Ordinance.;1iwtpare:Jae BE SIGNATURE OF RESPONSIBLE PERSON: