application SEPTIC DISPOSAL PERMIT APPLICATION Office Use Only
742 Bay Road,Queensbury,NY 8E O�2 -ZL�( �
Ih.,,„��rcLccnshw.` P:518-761-8256 www.quee� P ''
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-2 - P Fee: $ 7S• ; Invoice#: i 7S S
Tax Map ID#: 3( S . �o � � � .�L� � ��9 t
Project Location: Z9 -TO V'l'' k I)2,. -I Septic Variance? Yes No
TOWN Of QUECNSB -
Primary Owner(s) '6 cj, r"- e, tALf NG & CODES
Mailing Address 2c �-�rv�w,�r S b rZ b3 i '
Phone & Email (51�) �y 3-5'1b5
Installer/Builder �� (1 s cam' L S,e r-v
Mailing Address r- z S i SS o.) 12 S G\„ y \\ S t Z�p3
Phone & Email l SZ 1) 4E0- Li
Engineer
Mailing Address
Phone & Email
Contact Person for Building&Code Compliance: Phone:
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 i 1 -2_Lo
PARCEL INFORMATION:
Topography `Flat Rolling Steep Slope %Slope
Soil Nature ✓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 1 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 l SO ft.; Each Trench SC) 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 W �` 'rrl)C DATE: 11 " 15"L0t9
SIGNATURE: --4 �. �-� DATE: 1 S
Town of Queensbury Building&Code Enforcement Revised March 2018