applicationSEPTIC DISPOSAL PERMI
742 Bay Road,Queensbury,NY
518-761-8256.ww queen pon bp ~O104{~Wo
Tax Mapip#:$00 «1-40.|oe i Fee:§,L5G Invoice #:244%
Project Location:_3~ra a ofORALDe Safe)»_X no
Ton of Cacensbay
Primary Owner(s)cE Ere.glee
Mailing Address Y los V5.Gow =e AY
Phone &Ejpall y Zl ~Leuutain Serenity bebpe Bruin)Lawn
Installer/Builder <.v
Mailing Address £7 ‘VD Doveak Lure
Phone &Email oS oooy
Phone &Email
Contact Person for Building &Code Compliance:_</
—Le Phone:s/s 2/4047-O3/5 —
RESIDENCE INFORMATION:at ag OTe
Year Built #of bedrooms X gallons per bedroom_|=total daily flow Garbage Grinder Yes|Ng
1980 or older Installed?(circle one)
3
‘Spa or Hot Tub Yes|NoesetInstalled?(circle one)QI
1992-Present|2 Selywe
PARCEL INFORMATION:
Topography X Flat Rolling Steep Slope %Slope
Soil Nature X_Sand X%_loam Clay Other
Groundwater At what depth?—
Bedrock/Impervious material|At what depth?aDomesticWaterSupply_—Muni |_XWell (if well,water supply from any septic system absorption is Z<oft.)
Percolation Test,Rate:Zo"per minute per inch (test to be completed by licensed engineer/architect)Aj]ig .
PROPOSED SYSTEM FOR NEW CONSTRUCTION:&
Tanksize _[/eec?_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 __4 ft.
Seepage Pit with #3 stone How many:Size:
Alternative System Bed or other type:
Holding Tank System Total required capacity?;tank size 3#of tanks
NOTES:1.Alarm system &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.
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.
PRINTNAME:Jr EE Zige/e-c pate:_3 -/2-20
signature,“O-say OZ 2 ¢pate:_3-73 -2o
Town aad Kh smal Revised February 2017