application p
Office Use Only
Permit#: see"6 25311
SEPTIC DISPOSAL PERMIT APPLICATION Permit Fee: $ - ; Invoice#: ��-
- Septic Variance? Yes v No
Town of Q[icen.sbun
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net
Tax Map ID#: 2-4'8 • " S�
Project Location: 15 Fj ,y to\ t r o 1l\
t
• Applicant: l
Name(s): v,�-►e MOM ► e -c C
Mailing Address, C/S/Z: ` .5 i c:1 \Ca 1�
Cell Phone: _(5I )7q(,-5lp6ci Land Line: )
Email: c \bv\C\-,c4,(-4 � ���c $rear n e.y
• Primary Owner(s):
Name(s): l'1 M€ As e>sv
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: _(
Email:
❑ Check if all work will be performed by homeowner only
• Contractor: Workers' Comp documentation must be submitted with this application
Contact Name(s): ,P)ruc t
Contractor Trade:S-Ve.v tins n vx C-ek 'C\t y\
Mailing Address, C/S/Z:
Cell Phone: 1c`PR ) 4-0 - `1 Le 5 G) Land Line: _( ,
Email: I�i1
MAY 21 2019iJ i
• Engineer(s): TOWN OF QUEENSBURY
BUILDING&CODES
Name(s):
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: _(
Email:
Contact Person t.r Building & Code Compliance:Vyrijc,e, eAw. 0 ti,->
Cell Phone: r ) i- ®r - 7 LPSS Land Line: _(
Email:
CPntir Annliratinn Reviceri Fehrnary 7n14
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
9 v Installed? (circle one)
1992-Present 110
PARCEL INFORMATION:
Topography ✓Flat Rolling Steep Slope %Slope
Soil Nature -"Sand Loam Clay Other(explain:
Groundwater At what depth?
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: per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size 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 150 ft.; Each Trench fit, 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: DATE:
SIGNATURE DATE: 512-1\Zatat
Septic Application Revised February 2019