applicationTOWN OF QUEENSBURY
Date:
LOCATION OF PROPERTY FOR INSTALLATION:
omer's nane:_(rmanals
Installer's Name:/!s (UNI,Phone #2 775/852
Number of bedrooms (if residential):Y
Total daily flow (residential-compute @ 150 gal.per bedroom):(4)Topography-Circle One:(Flat)Rolling Steep Slope —_%of Slope—Sand Loam=Clay oehan 5 /Depth:Soil Nature-Circle One:
Ground Water-At What Depth?.Feet
Bedrock or Impervious Material-At What Depth?Feet
Percolation Test-Circle One:(Not.Required \Required/Rate Min.Per Inch
Domestic Water Supply-Circle One:“Municipal Well OtherIfdomesticwatersupplyisawellSeparation:Water supply from any Septic absorption feet
ANT NG
PROPOSED SYSTEM:Septic Tank 750.ar.(Minimum size:1,000 gal.)
Tile Field:Each Trench (ZO.feet//Total System Length GOO feet
Seepage Pit(s):Number of /Size each:ft.x ft.
Size of Stone to be used:#<A /Depth or Thickness /O/feet
ShearerHOLDINGTANKSYSTEMIF REQUIREDNo.of Tanks Size\of Each Gal.Alarm system and associated electrical work to be inspected by a certifiedagency.Seeeerereeeeeed
I have read the regulation on the reverse side of this sheet and agree to abidebytheseandallrequirementsoftheTownofQueéhsburySanitarySewageDjsposalOrdinance.Yo /
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SIGNATURE OF RESPONSIBLE PERSON:=0/77,paTE:_/3