application ` ,:' SEPTIC DISPOSAL PERMIT APPLICATION-=rOffice Use Only
742 Bay Road,Queensbury,NY 12804 �r�
Town of Qucenshun Permit#: �` 0 S(0 - k,5
P:518-761-8256 www.que2nsbury.net
Tax Map ID#: bp @, , 1 b - Permit Fee: $�r - ; Invoice#: 16110
Project Location: c\ TtwtirnpY SeVtic va i n ? r. ves r, I No
Primary Owner(s) IL)) g_ 1 jl I
Mailing Address \h i y, i 0' 'i it 1 ( I �i I /
r 1
Phone & Email b i a` rt j -
Installer/Builder A ) _SC'p -i•OWN OFQUEENSBURY
'�4Z RIM nl r& CODES
Mailing Address L0- v f- kthif r _ •fi QV
Phone & Email /s- `f it(' J K
Engineer :D
Mailing Address
Phone & Email Contact Person for Building&Code Compliance: (kvi
Phone: 11'" iS
V 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 1 j y T a n
PARCEL INFORMATION:
Topography / Fla oiling Steep Slope %Slope
Soil Nature / and Loam Clay Other
Groundwater At wh depth?
Bedrock/Impervious material At at 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 I-01 '► 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 LC) r) ft.; Each Trench 5-0 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 &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.
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. ' ,
' , q
i
PRINT NAME: k �) k ( Iti i/ DATE: L
/ _ r., L7
SIGNATURE: DATE:
Town of Queensbury Building&Code Enforcement Revised March 2018