application • � - '1 � � � � � � Office Use Only C
= SEPTIC DISPOSA 4 • � , le Permit#: .Se� 0 `t s-v ---261
3 2019 , Permit Fee: $ 7S- Cr.); Invoice#: �z
JULSeptic Variance? Yes No
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.aueensbury.net TOWN OF QUEENSBURY
BUILDING& CODES
Tax Map ID#: G c 3. 3 - 1 --S ?..--
Project Location: /40 Kô/Is éJ.. Noph,
,
• Applicant: CA �' 1 ' Seouli ip_s ,..A,.0 ��/
Name(s): ��V1n� W/1 �- �l V���- 0.
Mailing Address C/S/Z: el //& - Par Coolers N- 12-15-1
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Cell Phone: _( ) 9(0 Land Line: _( )
Email: °few Ometi On1�4/2.} /,CO/►7
• Primary Owner(s): v
Name(s): I�N O(hct Jiricj - 8 -Q-
Mailing Address, C/LZ: , . no lNYM A ,.i • l “)
Cell Phone: _(3) ' Land Line: _( )
Email: `7t1.ci @- ;, 00 Ayr)
❑ Check if all work will be performed by homeowner only
• Contractor: Workers' CP p documentation,must be submitted with this application
Contact Name(s): Scan I I�xcatce/CJY) iGC --
Contractor Trade: EKOct o+nlS Aw � /J
Mailing Address, C/S/Z: 0805e .3 Z W2f 1 /NY /?
Cell Phone: _(<7 ) ( 5f-7f1' Land Line: _( )
Email: 5eCtn -t.J�J-eAvez't l r.Oemi
• Engineer(s): /
Name(s): rr`f ,an S Qr)
PE
Mailing Address,
''C/S/Z: fir J laitAge, LZccZ f
Cell Phone: _(, ) S " 3t S S-- Lan Li ee.:y_( )
Email: /6/flcC (/ CC*7
Contact Person for Build & ode C Ai, 1 b.,nno
P d(&
Cell Phone: ( �' ) _ - �o� fiance:Land Line: ( )
Email: Y)0 CO L -njerviail. coo)
Septic Application Revised February 2019
RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms: X gallons per =total daily flow
per day bedroom Garbage Grinder Yes a
1980 or older 150 Installed? (circle one)
1981-1991 130 -zj Spa or Hot Tub Yes rho
Installed? (circle one)
1992-Present 110
PARCEL INFORMATION:
Topography )( Flat Rolling Steep Slope %Slope
Soil Nature f Sand _Loam _Clay Other(explain:
Groundwater At what depth? IQ n�
Bedrock/Impervious material At what depth? f G
Domestic Water Supply _Municipal j 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)
nkS
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size (0(.,0 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 t-(. ft.; Each Trench (-tic ft.
Seepage Pit with #3 stone How many: 3 ; Size:
Alternative System Bed or other type:
Holding Tank System Total required capacity? ;tank size Law ;#of tanks I
NOTES: 1.Alarm system and 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. 3. As-built drawings must be
submitted prior to the inspection, if there has been a change to the submitted plans.
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: 1VCLoft7S I (4O DATE:
SIGNATURE: DATE:
Septic Application Revised February 2019