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Office Use Only Permit#:SEP -005-20 29SEPTICDISPOSALPERMITAPPLICATION|permit ree:$s Invoice DALE Septic Variance? Tow of Qucenshary ‘742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.queensbury.nct Tax Map ID #:0H.'A-Lae IB Project Location:|I]U jee ¢Applicant:‘ Name(s):Hine Las teller Mailing Address,C/S/2:_¥3ex Kr,G0 (Sarufoga,WV (284g Call Phone:_{5/8 )_232-LI04 land Line:(272 )_S8¢-oREmail:cin ©shoviti dv strics 1 Gorm .Primary Owner(s:Name(s):Ifenns Z.<Mailing Address,C/S/Z:_¢3 Aucije Ave.Clucensbury,VE [2804 Cell Phone:(578 )Zip 275g Land Line:_() Email:b fecck aire,ety 5 LP Suns |Cosas O Check if all work will be performed by homeowner only ©Contractor:Workers’Comp documentation must be gubmitted with this application Contact Name(s):Ln stitfetioss -p Bard-al. Contractor Trade:Wag Pe eurfei.Sys £ Mailing Address,C/s/2:__#7or Lte,So Sarutese WE +2sd¢ Cell Phone:(3/8 )Z232-Zyo7 _ landline:(9K)ERP-~10 4Email:Fan(@ Foacimductries Gove «Engineer! Name(s): Mailing Address,C/S/Z: Cell Phone:_()land Line:_() Email: Contact Person for Building &Code Compliance:Deas [Sots fe Cell Phone:1518)BZ-LI0.land Hine:(57B)SRY OYEEmail:Stu @ sFeve wdvstmes Com RESIDENCE INFORMATION: Year Built [Gallons|#of bedrooms:|X gallons per |=total daily flow r day bedroom Garbage Grinder Yes (Ro 1980 or older|150 | Installed?(circle one) [981-1991 730 T |‘Spa or Hot Tub Yes (Ro) Installed?(circle one)1992-Present|110 3 {10 330 PARCEL INFORMATION: Topography Flat Rolling Steep Slope %Slope Soil Nature X Sand __loam _Clay Other (explain:) Groundwater ‘Atwhat depth? Bedrock/Impervious material|Atwhatdepth?——___Domestic Water Supply £Municipal___Well (if well,water supply from any septic system absorption is___ft.) Percolation Test Rate:if"__per minute per inch (test to be completed by licensed engineer/architect) rT PROPOSED SYSTEM FOR NEW CONSTRUCTION: Tanksize|J 200 gallons (min.size 1,000 gallons,add 250 gallons for each garbage cylinder or spa/hot tub System.Absorption field with#2stone.|Totallength JO ft;EachTrench_75 ft.ARC-2E Seepage Pit with #3 stone How many:;Size:Drevetleas Is, Alternative System Bed or other type: Holding Tank System Total required capacity?;tank size 3 #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.|have read the regulations and agree to abide by these and all requirements of the Town of Queensbury Sanitary Sewage Disposal Ordinance. PRINT NAME:Kee Dard e.DATE:PZ.“peeo SIGNATURE:.2 pK>)A TF oare:_2-20.20 Seoti Avolication