applicationOnnaSl a AUYNASNAAINO
AO
NMGApplicationfor|SEPTIC DISPOSAL PERMIT
STAMP Ri
IAD
atv $25,80
VED
do.
(29
¥
prone #:192-4648
Owner's Mailing Address:
Installer’s Name:
‘Topography:Xi [1 Rolling 7 steep Stope
Soil Nature:Exon CD tom—chy otter
Ground Water:at what depth?feet
Depth:——__.
Bedrock oF Impervious Material:al what depth?————_—feet NOV 05 1996
Percolation ‘est XX Not Required
Domestic Water Supply:ie Mun
If domestic water supply is «WEILL:water supply from any septic absorption is —_____feet
ed/Rate5went3 other
PROPOSED SYSTEM:
Sion in sin ety OSE 1,000 gulorNile,9 eet SOL ns,
Scepage Pil(s):umber of _________/size each:fx hesarinoirIOpce
‘ile Field:cach tre
Size of stone to be used:
HOLDING ‘TANK SYST crrewirey|NPL
Number of tanks:=Size of each:gal.
Ins |Alarm system and associated electrical work to be inspected by a certified agency.
For your protection,please note that pursuant to Section 136-29 ofthe Code ofthe Town ofQueensbury,any permit or approval granted which is based upon or is granted in reliance upon
any material misre presentation or failure to make a material fact or circumstance known by or onbehalfofanapplicant,shall be void.
Thave read the regulations with respect tothis a pplication and agree to abide by these and ull
requirements of the Town of Queeee aOe
awe LNA