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applications Application for Permit"Septic Disposal System Town of Queensbury 742 Bay Road Queensbury,NY 12804 (518) 761-8256 1. OWNER INFORMATION: --..- ...............................- ......... omee Use Location of installation:_�.�. C" File Permit No. '1 Q Tax Map No. 21,6/ 112,. Fee Paid Owner's Name: ` `1 �Z ..- . ..- ...,................n...............-- �. -�.�.._-..-....-...,........ Address- 2. INSTALLER'S NAME PHONE NO. 3. RESIDENCE INFORMATION: (circle year of dwelling,indicate#bedroom(s) and multiply#of bedrooms with applicable gallons per bedroom to equal total daily flow) Year of House: No of Bedrooms x Computation a Total Daily Flow 1980 or older x 150 gal/bdrm = � _ 1980— 1991 x 130 galtbdrm = 1991—present x 110 gal/bdrm a Garbage Grinder Installed yes_.__ / no Spa or Hot Tub Installed yes—,__./ no 4. PARCEL INFORMATION: (circle applicable information&indicate measurements) oQraphv Soil Nature Ground Water Bedrock or Impervious Material._ Dgmestic Water SUpply Flat sand at what depth at what depth municipal Rolling loam e _feet well Steep slope clay dwell,water supply slope other from any septic-system depth: absorption is ft. other Percolation Test: (To be completed by licensed professional engineer or architect) Rate: minute per inch 5. PROPOSED SYSTEM: ]'or Ngw-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. Septio Tank: gallon(min. size 1, 00 gal) Tile Field: each trench T tal System Length: ft. Seepage Pit(s): number of of each: ft. by ft. Size�f Stone to be used: # / epth or thickness feet Bed System Size: x Alternative System: length and/or size 6. HOLDING TANK SYSTEM: (if required) Number of tanks: Size of each: 1-<�4D gallons /TOTAL Capacity: © gallons Note: Alarm System and associated electrical work must be inspected by a Town approved electrical inspection agency. 7. SIGNATURE &INFORMATION FOR RESPONSIBLE PERSON(please read) 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 f of an applicant, shall be void. I have read the regulations with re ect.t this application and agree to abide by these and all requirements o e Tofn of Qu JAY Sanitary Sewage Disposal Ordinance. Signature of r spons.ibie person Date Building Permit Application Town of Queensbury—Dept of Community Development,742 Bay Road,Qutiensbury,NY (518)761.8256 A permit must be obtained before begimning constriction. Permit File No No I ection will be made until applicant has reoeived a Fee Paid S (� valid building permit. All applicants' spaces on this Roc.Fee Paid $ application must be completed snd must appear on the Reviewed By: application form. Applicant. 1 �'� [L Addt�ess• Address: v C L Phone#{,_,) Phone# Property Loostion: Lot Number. / House Number Subdivision Name• Tax Map Number: z 2 G i Z; o New Building: residence /commercial `Estimated Market Value of Construction: $ a Addition: tuklomI commercial if tdditim what will use of new addition be? Alteration: dent commercial A k � o No obange to Wderlor : residence/co&I a Other work<desadbe Check occupancyWormation V Floor 2. Floor otter floor Total Below sq.ft. sq.ft. eq.ft. Square Poet k4y- Sin a Amily dwelling c�C•.'1' 2 . l /ca Two family dwe o Townhouse o M X dwelling #Of=its 0 office o Mere * o Mt3au 0 1 oat detached EnLo 0 2 oar detached em 0 3 oar detached eme 0 1 on Attached Imp Z ou t uAQhed 1 v 3 a r attAehed pNe o Stcmage building- oommerdal a Storm building- resideatW 0 o er What is the proposed height of the structure.. feet inches Will nay second-band or ungraded lumber be used? Tf so,for what? Type of nesting System: electric/ oil / gas I wood /forced hot air/ baseboard/other: Number of Zkga[M to be ir<s_talled Number of Woods jyjj to be installed List below the person(s)responsible for supervision of work as regards to building codes: Name Address Phone Number Builder I DAT wit Z L Plumber ►r 4 MW a $lectric,j= I << `L j2e2jAMjZ- please sign below after you have carefully read the statement: To the best of my kmowledge the statements contained in this application,together with the plans and specifications submitted,are a true and complete statement of all proposed work to be done on the described premises and that all provisions of the Building Code,th Zooning Ordinance and all other laws pertaining to the proposed work shall be eompliod with,whother speciSed or notWsadl#hat such work is authorized by the owner. Further,it is understood that Tlwo shall submit,prior to a Cptff te of Compliance being issued,as requested by the Zoning Administrator Ds Built Survey by a licensed surveyor;drawn to scale,showing actual location of all Signature: owner,owner's agent,architect,contractor