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SEP-0507-2019 Office Use Only Permit#: P - 050-+- -2-53-‘.c7 SEPTIC DISPOSAL PERMIT APPLICATION Permit Fee: $ }5 ; Invoice#: 1845 ro �rcZ���sn�ry Septic Variance? Yes ✓ No 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.queensbury.net Tax Map ID#: 339. ? —/- / 2 Project Location: 0/ 3 (P/ /i/ .' / • Applicant: Name(s): L tO0A rvl o. �At2 / �/ Mailing Address, C/S/Z: 3 &Ayr- 1,�4 j ,4 j-e , o()eakCSv/y A)c V Joll6 qCell Phone: _( S i� ) /( 3 ed cUctvi �- Land Line: _( Email: OY / • Primary Owner(s): Name(s): � r �7 /4 i(t. ) i/q @k Mailing Address, C/S/Z: 3 Qe4A-),'i lkv.DGOU,ft i'i,/ A/,-A,e.Aa c/ Cell Phone: _( S i ) l J 2 -o q S' Land Line: _( Email: Check if all work will be performed by homeowner only • Contractor: Workers' Comp documentation must be submitted with this application Contact Name(s): Contractor Trade: Mailing Address, C/S/Z: A 'r Cell Phone: _( ) Land Line: _( Email: • Engineer(s): Name(s): Mailing Address, C/S/Z: Iv /i Cell Phone: _( ) Land Line: _( Email: JUL 29 TOWN OF QUEENSBURY BUILDING& CODES Contact Person for Building & Code Compliance: 7DI Cf4 Cell Phone: ( 5/ ) `��3 J' Land Line: _( Email: Septic Application Revised February 2019 RESIDENCE INFORMATION: Year Built Gallons #of bedrooms: X gallons per =total daily flow per day bedroom Garbage Grinder Yes No, 1980 or older 150 .3 Installed? (circle one) X 1981-1991 130 Spa or Hot Tub Yes No Installed? (circle one) X 1992-Present 110 PARCEL INFORMATION: Topography Flat Rolling Steep Slope X %Slope Soil Nature k Sand _Loam Clay Other(explain: Groundwater At what depth? Bedrock/Impervious material At what depth? Domestic Water Supply _Municipal X Well (if well,water supply from any septic system absorption is//(eft.) Percolation Test Rate: / per minute per inch (test to be completed by licensed engineer/architect) PROPOSED SYSTEM FOR NEW CONSTRUCTION: Tank size I1 T 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 ft.; Each Trench ft. Seepage Pit with #3 stone How many: Z ; Size: 6 Xcr k e Alternative System Bed or other type: b,p ty 1 Holding Tank System Total required capacity? ;tank size/80 ;#of tanks 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: L I /�)Q /LI 0 IAirk DATE: / - 0 / ' < F SIGNATURE: 4-101k I A ( [I46Z DATE: / pl 9 -/ Septic Application Revised February 2019 TOWN OF QUEENSBURY 742 Bay Road, Queensbury, NY 12804-5904 (518) 761-8201 Community Development - Building & Codes (518) 761-8256 BUILDING PERMIT SEP-0507-2019 Permit Number: 309.9-1-42 Tax Map No: Jody Clark Permission is hereby granted to: 23 CENTRAL AVE For property located at: In the Town of Queensbury, to construct or place at the above location in accordance with application together with plot plans and other information hereto filed and approved and in compliance with the NYS Uniform Building Codes and the Queensbury Zoning Ordinance Type of Construction Linda Clark$0.00 Owner Name:Septic Disposal-Residential Owner Address:23 Central AVE Total Value $0.00 Queensbury, NY 12804 Contractor or Builder's Name / AddressElectrical Inspection Agency Plans & Specifications Residential Septic Alterations (new seepage pit and D-Box) $75.00 Wednesday, July 29, 2020 PERMIT FEE PAID - THIS PERMIT EXPIRES: (If a longer period is required, an application for an extension must be made to the code Enforcement Officer of the Town of Queensbury before the expiration date.) Tuesday, July 30, 2019 Dated at the Town of Queensbury SIGNED BY:for the Town of Queensbury. ________________________________ Director of Building & Code Enforcement 'Nl . cc WI �,' New emu: ( L. : N W©. WI 2 ppqq --I0Q -R Z IA Oco `5 �`klsI") J iruch. 4- J £ I �iW"'' TOWN OF QUEENSBURY AN FG4r►A4Ytv�., BUILDING & CODES DEPT. Reviewed By: / Date: ?� r( :T .9-1-42 ac9rk, Linda SEP-0507-2019 FILE GOP% entral qve Residential Septic Alteration e r_NTRA4 _ ' � � AS BUILT 1-5 001 10 - TOWN OF QUEENSBURY � ~- BUILDING _ CODES Reviewed By: �--------------~-�- --------------- ----------____i } � ` ���m� ' ,~~°^� | Clark, Lind. SEP-0507-2019 | Ave23 Central Residential / � ,