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applicationOffice Use Only Permit #:Ab\|-Toeo Permit Fee:§7S‘CD;Invoice #:_2 YY.|Septic Variance?Yes No SEPTIC DISPOSAL PERMIT APPLICATION | t Town of Queensbury 742 Bay Road,Queensbury,NY 12804 0)war 09 2020 5187618256,war gucenburynet | TaxMapID#:_5SAZ3 400 266 ,3-/-s6 Project Location:|V3 Ridge Rd,Quoenshury ¢Applicant: Name(s):_Damna HoskiaS Mailing Address,C/S/Z:1@3u Ridge Pal Quaens bue NY 12-04 Cell Phone:_(5/%_)6%3-2 013.land Line:(51%)792-66 © Email: ¢Primary Owner(s): Name(s):__Joyce Wi Ic ox Mailing Address,C/S/Z:13 Ridge Rd Qusenshury NY lago4 Cell Phone:_()_none,landline:(51S)792.~6 6 @/ Email:_yung O Check if all work will be performed by homeowner only *Contractor:Workers’Comp documentation must be submittedwiththisapplication Contact Name(s):Hatt’ssey Conshoken treContractorTrade:PACacoke,Corskrus here Mailing Address,C/S/Z:_AV Jt S0l poped Rel Fact Qan AX Ln g27 Cell Phone:_(_61¢).3Z)Ya2d Land Line:_() Email: ©Engineer(s):n /Name(s): Mailing Address,C/S/Z: Cell Phone:_()Land Line:_() Email: Contact Person for Building &Code Compliance: Cell Phone:_()Land Line: Email: entie Annlratinn Revised February 2019 RESIDENCE INFORMATION: Year Built [Gallons|#of bedrooms:|X gallons per per day bedroom Garbage Grinder Yes|(6)|1980 or older|150 qd |Installed?(circle one) 7981-1991 30 ~Spa or Hot Tub Yes (No)-Installed?(circle one)| 1992-Present|110 PARCEL INFORMATION:__ Topography 7 Flat Rolling Steep Slope.%Slope Soil Nature __Sand loam —__Clay___Other (explain:) Groundwater ‘At what depth? Bedrock/Impervious material|At what depth?3DomesticWaterSupply__Municipal _,Well (if well,water supply from any septic system absorptionis__ft.)_| Percolation Test Rate:per minute per inch (test to be completed by licensed engineer/architect) PROPOSED SYSTEM FOR NEW CONSTRUCTION:\QoKing ato Currant leach oldTanksize|{5 Ogallons (min.size 1,000 gallons,add 250 gallons for each garbage cylinder or spa,3System‘Absorption field with #2 stone_|Total length ft;Each Trench ‘Seepage Pit with #3 stone How many:;Size:__Alternative System Bed or other type:Holding Tank System iTotalrequiredcapacity?tank size 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. Donna Hoskms Deon Hohe vate:3 ~A-20 pate:_3-2-2O PRINT NAME: SIGNATURE: Septic Application Revised February 2019,