application 1
' ,I SEPTIC DISPOSAL PERMIT APPLICATION Office Use Only
-= 742 Bay Road,Queensbury,NY 12804. Vf�
Tosrn of(>ucenshun' „.' _ Permit--# `�a�` '" —e-01 7
P:518-761-8256 www,ciueensbury.netc`
Tax Map ID#: 3O ` I ",, TM Permit`Fee S ,Invoice#: /64,S
\ (../ ..)-)- p'1 JUN 1
Project Location: �� 41 \ U septic Variance? Yes No
Primary Owner(s) 30
N p-i. a s _° 1,A OF ug� ,f :z;
Mailing Address #1 f i \ Cce — -C- ° - ' � t ."� —,s
Phone & Email 131 c.-19a.-3'L 7
Installer/Builder 16 5 J-c Qi-Q L
Mailing Address `)— 123vw -er (Ai“)(N. '- -, (wasp,5 o(,4r�
Phone & Email �,—lq- S S)
Engineer
Mailing Address
Phone & Email
Contact Person for Building&Code Compliance: .,(/N/ ( e Phone: ' I
RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms X gallons per =total daily flow
per day bedroom Garbage Grinder Yes No
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1980 or older 150 Installed? (circle one)
1981-1991 130 Spa or Hot Tub Yes N
Installed? (circle one)
1992-Present 110 3 ( 7/ ' i 0
PARCEL INFORMATION:
Topography i at Rolling Steep Slope %Slope
Soil Nature Sand Loam Clay Other
Groundwater At w at depth?
Bedrock/Impervious material At hat 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 SYST 11(I�FOR NEW CONSTRUCTION:
Tank size e �,� allons(min. size 1,000 gallons, add 250 gallons for each garbage cylinder or spa/hot tub
System Absorption field with#2 stone Total lengtl L-C ' ft.; Each Trench 1, r) 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.
have read the regulations and agree to abide by these and all requirements of the Town of Queensbury Sanitary Sewage
Disposal Ordinance, r PRINT NAME: C /1r �mk er & (I DATE: ().--)q—(ci-
SIGNATURE: DATE: 6`-d Lid ✓F
Town of Queensbury Building& o Enforcement Revised March 2018