applicationSEPTIC DISPOSAL PERMIT APPLICATION
742 Bay Road,Queensbury,NY 12804
Office Use Onl
P:518-761-8256 www quconsbury net Permit#:DEP -O\Ne -2920
Permit Fee:$>_;invoice ms 2455ProjectLocation:7)Dy oad A CL5 PA|seotievarance?ves No
Lia)
Tax Map ID #:
Primary Owner(s)|Mailing Address ad|Phone &Email 74)xInstaller/Builder p
Mailing Address|Phone &Email
[Engineer
Mailing Address
Phone &Email (X-“4 QO.
RESIDENCE INFORMATI
Year Built|Gallons|#of bedrooms |X gallons per|=total daily flow -per day bedroom Garbage Grinder Yes ry)1980 or older}150 Installed?(circle one)|
7981-1991 Bo Spa or Hot Tub Yes|NiInstalled?(circle one)1992-Present|110 u LtHo7 44gPARCELINFORMATION:
Topography —Lporram Steep Slope %SlopeSoilNatureSandloamClay_—__OtherGroundwaterAtwhatdepth?:
Bedrock/Impervious material |At yfhat depth?Domestic Water Supply Municipal ____Well (if well,water supply from any septic system absorptions i)Percolation Test Rate:Per minute per inch (test to be completed by licensed engineer/architect)PROPOSED SYSTEM FOR NEW CONSTRUCTION:||Tank/size sallons (min.size 1,000 jallons,add 250 gallons for each garbage cylinder or spa/hot tubSysjem__|Absorption field with #2 stone|Total length ___ft;Each Trench ftSeepagePitwith#3 stone How many:Size _|Alternative System Bed or other type:LOX}5L|Holding Tank System |Total required capacity?j tank size 3 #of tanksNOTES:*-Alarm system &associated electrical work must be inspected by a Town approved electrical inspectionTats2Wewillnolongerallowsystemstobecovereduntilsuchtimeasanas-built plan is received and approvedTheinstalledsystemmustmatchthesepticlayoutonfile—no exceptions
Declarat ny permit or approval granted which is based upon or is granted in reliance upon any materialrepresentationor
Disposal Ordinance.
PRINT NAME:Che st her Bell
DATE:Yeh 19
SIGNATURE:onre:3-1 6-20
{Town of Queensbury Building &Code Enforeerent Revised March 2018