application Office Use Only
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Permit#: - ��� ."2 4.
-0SEPTIC DISPOSAL PERMIT APPLICATION Permit Fee:$. ,tax Invoice#:
1 Septic Variance? Yes No
Town of Queensbury
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 vmwrw.queensburv.net • . -- W
le CEO
Tax Map ID#: 3 0 , l —I` i.— s-Z N MAY 02 2019
Project Location:55 6 req.JOOC i t F vzsbux ' I .1 ' 'o N OF C UEENSBURY
BUILDING&CODES
• Applicant:
Name(s): i ci:90 re 8iayuiclit Mailing Address, C/S/Z: 1'3 Ip C'1er '2a, i e.Li-1s t?vUVLi 1\11 ij k 0
Cell Phone: (5i i )413,1 -'14 i 0 Land Line: _(.I g ) 1y5'117 iv
Email: fOr2S-1- rl p.r hp.T proper*i es. f'r vVI
• Primary Owner(s):
Name(s): Fore:s+ Pc VYI i-V , u—e,
Mailing Address, C/S/Z: SC,Y _Q` f.Uj Ct_0cArc, --
Cell Phone: _( ) _ Land Line: ( ) _
Email:
0 Check if all work will be performed by homeowner only
• Contractor: Workers' Comp documentation must be submitted with this application
Contact Name(s): I�C'_Ourt OLurcUCk.
Contractor Trade: .` pl-i e I v't -f to1,1S
Mailing Address, C/S/Z: 4 305 kOute .mi0 ei.rcliT'aC.cySi I:(1�s I,1 l 2.g ike —
Cell Phone:_(51 c ) , ,3 A C.c'1 O 1 Landa Line: _(51 8 ) 58`1-t€til
Email: abaft C sitne)n.ctt.3fari es,e001
• Engineer(s):
Name(s): gian Riper Mailing Address, C/S/Z: 2-25 2991 c r , i7li r ' eL\ l 1 1°) 4° —
Cell Phone: _(5i ' _) I 1 - i..N Land Line: _ —)
Email: Pert irl .ipcf e kk eirtut.triyi. uc
Contact Person for Building & Code Compliance: )Ya. ll'..-Gt.1sl..trii — _
Cell Phone:,_( `1 q ) .3a-1q 1 0 Land Lin` : _(D1 g ) -7 y -1-7-1 (-0
Email: -i't)r e -i-pcLn e r trip --p 1tO X-t-i ; ca0 tit)
Septic Application Revised February 2019
RESIDENCE INFORMATION: _
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 0 1(( 3L _
PARCEL INFORMATION:
Topography V Flat Rolling Steep Slope %Slope
Soil Nature v`4 Sand _Loam Clay —Other(explain: )_
Groundwater At what depth? 2.5 _
Bedrock/Impervious material At what depth? `° _
Domestic Water Supply Municipal _Well (if well,water supply from any septic system absorption is ft.)
Percolation Test Rate: I '-13 _per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size I COC 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 /0 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 and 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. 3. As-built drawings must be
submitted prior to the inspection, if there has been a change to the submitted plans.
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: �`16-roa;'o bCL6'i Kcin — DATE: ---- � ; LI
SIGNATURE: { j �t�C�aL '1i� iC` C� DATE:- -� ` ! 9
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Septic Application Revised February 2019