application 0 SEPTIC DISPOSAL PERMIT APPLICATION—_, _Office_Use Only
_f c e.%` 742 Bay Road,Queensbury,NY 128Q4i) f P
lossn of(ucensburc �d IfT i Ser_0373 ----Lot?
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P:518-761-8256 www.queensbury&ft ___
Tax Map ID#: -30 G' I' I I If JUN) ii 2C'�eml Fee:$7W ; Invoice#: � '
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Project Location: r sv5 1 v . n 0 -- .-_.Sep is Variance? Yes No
3 WN Or0t,i�F`V it v.
Primary Owner(s) l,ul its a & cpDEs 1
Mailing Address I ) 5 r P P JN
Phone & Email +7 ,0- �w
Installer/Builder lit 5 5-egr'f`
Mailing Address - 1 Z � -er A 01ri" ^` 4-
Phone & Email J l -19. ICJic 1
Engineer E t$ li,l
Mailing Address \V-1. 0a)C i\ve 6- l-Pr k
Phone & Email S l V i I-u1:1.
Contact Person for Building&Code Compliance: of n r 03. ,\,I Phone: 51 -3 hI—) F6c
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) �f
1981-1991 130 /? Spa or Hot Tub Yes No/
Installed? (circle one) �a//
1992-Present 110 110 d 0 1-1".�,0
PARCEL INFORMATION: i l
Topography i
¢lat Rolling Steep Slope %Slope
Soil Nature V Sand Loam Clay Other
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 L1,1O gallons (min. size 1,000 gallons, add 250 gallons for each garbage cyliindSr or spa/hot tub
System Absorption field with#2 stone Total length -Ion ft.; Each Trench `T C 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.( "
PRINT NAME: C ) fy0T/ ( I DATE: to71 I —I
C)
(4 I-11).
SIGNATURE: DATE:
Town of Queensbury Building&Cod forcement Revised March 2018
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