2008-471 -� -� OFFICE USE ONLY r ; r ;
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0 TAX MAP NO. PERMIT NO. ," -� �' ,4RMIT FEED' --� i
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APPROVALS: ZONING TOWN CLERK_ ;
APPLICATION FOR SEPTIC DISPOSAL SYSTEM PERMIT;
A PERMIT MUST BE OBTAINED BEFORE WORK BEGINS.APPLICATION IS SUBJECT TO REVIEW BEFORE ISSUANCE OF A VALID
PERMIT.
OWNER: STALLER:
ADDRESS:�ta� S �/ln v a c/( ADDRESS:
PHONE NOS. PHONE NOS. �9 Lf Y
LOCATION OF INSTALLATION:
...........ti.......................................................................................................................................:.................................. RESIDENCE INFORMATION:
YEAR BUILT BEDROOMS X i COMPUTATION- i TOTAL DAILY FLOW
..................................................................... ................................ ;...........,.................... GARBAGE GRINDER
I 1980 or older 7.............................................. _ `......................................... INSTALLED X 150 gallon per bedroom i ?
1981 1991 X i 130 gallon per bedroom _ { SPA OR HOT TUB
I 1992 present i X ; 110 gallon per bedroom = i INSTALLED?
I...............-..........................„.J......... ,............,............;.......................................................................::.....,.,...i.........................................................................
PARCEL INFORMATION:
✓ TOPOGRAPHY: FLAT ROLLING_�STEEP SLOPE %SLOPE
✓ SOIL NATURE: SAN LOAM CLAY OTHER
✓ GROUNDWATER: T WHAT DEPTH? BEDROCMMPERVIOUS MATERIAL: AT
WHAT DEPTH?
✓ DOMESTIC WATER SUPLY: MUNICIPAL. WELL
(1F WELL:WATER SUPPLY FROM ANY SEPT! -SYSTEM ABSORPTION IS FT._)
✓ PERCOLATION TEST: RATE IS—
PER MiINUTE PER INCH (TEST TO BE
COMPLETED BY A LICENSED PRAESSO' NAL ENGINEER OR ARCHITECT)
PROPOSED SYSTEM FOR NEW CONSTRUCTION: All individual sewage disposal systems must be designed by
a licensed professional engineer or architect (unless installed in a Planning Board approved subdivision). Add 250
gallons to the size of the septic tank and leach field for each garbage grinder, spa or whirlpool tub.
✓ SEPTIC TANK: Ci XI ION (MIN. SIZE IS 1,000 GAL.) TILE FIELD: EACH TRENCH FT.
✓ TOTAL SYSTEM LENGT 00 FT. SEEPAGE PIT(S): HOW MANY?
✓ SIZE OF EACH_AZ= ' T. X FT.
✓ SIZE OF STONE TO BE USED: # /DEPTH OR THICKNESS FT.
✓ BED SYSTEM SIZE:W—�4- X
✓ ALTERNATIVE SYSTEM: /l,f LENGTH AND/OR SIZE l —
✓ HOLDING TANK SYSTEM:(If required) NO. OF TANKS: /SIZE OF EACH_ IV-4
✓ GALLONS./TOTAL CAPACITY.,. GAL.
:................................................:.:.:...:.:.:,. ,.:.:.,.:.,.,.,.:...................:.......:...,.:...,.:.:.,.,.:.:.:.:.,.:.:.,.,.:.:.:.:.::..:.:.:.,.:.:.:..::...:.....,...,.,...:.....:.....,.:.....:.:.:.,.........................:,.....:::.,:,,,... ,.,:,:. . , :. :
l NOTE: ALARM SYSTEM AND ASSOCIATED ELECTRICAL WORK MUST BE INSPECTED BY A TOWN
APPROVED ELECTRICAL INSPECTION AGENCY PLEASE REVIEW LIST PROVIDED.
For your protection, please note that pursuant to Section 136-29 of the Code of the Town of Queensbury, any
permit or approval granted which is based upon or is granted in reliance upon any material misrepresentation 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 with respect to this application and
agree to abide by these and all requirements of the Town of QUESTIONS? CALL 761-8256 OR EMAIL
Queensbury Sanitary Sewage Disposal Ordinan e. codesCaueensburv.net
VISIT OUR WESSITE FOR MORE INFORMATION
p Jd www.gueensbury.net
Sign a of Person Responsib a Date l
Town of Queensbury • Community Development Office • 742 Bay Road, Queensbury, NY 12804
Septic Inspection Report
Office No. (518) 761-8256 Date Inspection request received:
Queensbury Building &Code Enforcement Arrive: am/prt: am/pm
rpe*
742 Bay Rd., Queensbury, NY 12804 Inspecto s Initials:
NAME: PERMIT NO.: ;71
LOCATION: i1�RlitA,4 AV INSPECT ON:
RECHECK:
Comments and/or diagram
Soil Type: Sand Loam Clay
Type of Water: Municipal /Well Water
Waterline separation distance ft. Gf
Well separation distance ft.
Other wells: ft.
Well Casing Length 50' + / - Y N_N/A
Absorption Field: Total length ft.
Length of each trench ft.
Depth of trenches ft. /O Apu,,�,
Size of Stone
Seepage Pits: Number /
Size: x
Stone Size:
Piping Size Type
Building to tank
Tank to Distribution Box
Distribution Box to Field Pit
Opening Sealed: Y N
End Cap Y N
Inlet/Outlet Pipes&Baffles Y N
Location Separations
Foundation to tank ft.
Foundation to absorption ft.
Separation of Pits ft.
Conforms as per Plot Plan Y N
Engineer Report and As-Built Y N
Location of System on Property:
Front Rear Left Side Right Side Middle Front Middle Rear
System Use Status:
Approved
Partial Approved and needs to be re-inspected, please call the Building &Codes Office
►/Disapproved
Last revised 06/18/07 L:\Building&Codes Forms-OLD\Building&Codes\Inspection Forms\Septic Inspection Report.doc
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