applicationSEPTIC DISPOSAL PERMIT APPLICATION|office
use
only
eet Eee eymy veimcn SEC-BIA4-2029
Tax MapiD#:__0%.>)!Permit Fee:$YO ;invoice #:AES)Project Location:1 W My Gd,Septic Variance?___Yes___No|Primary Owner(s)Jave CON ooMailingAddress\I 4 I.a —
Phone &Email 5 18-955-4 005Installer/Builder AS Septic |Mailing Address 2 Lowes St.QueensburyPhone&Email FLY 193-9194 y
Engineer AEPEII|Mailing Address Y=—|Phone &Email
DLT apr 03 2029 _|Contact Person for Build ||
&Code Compliance:Cha 4 (All S Phone:14-2)61 LY 65SENG:ESE oro si|RESIDENCE INFORMATION:BUILD!CODES,
Year Built|Gallons|#of bedrooms|x gallons per|=total dally flow _per day bedroom Garbage Grinder Yes|No1980orolder|150 --~|Installed?(circle one)1981-1991|230 ‘Spa or Hot Tub Yes |Nob.Installed?(circle one)1992-Present|110 4 |4 |
5 yO
PARCEL INFORMATION:
Topography 7 fiat Rolling Steep Slope %SlopeSoilNatureVsandLoamClay’Other |Groundwater At what depth?
_Bedrock/Impervious material|Atfvhat depth?
-Domestic Water Supply Municipal__Well if well,water supply from any septic system absorption is __ft)|Percolation Test Rate:er minute per inch (test to be completed by licensed engineer/architect)PROPOSED SYSTEM FOR.NEW CONSTRUCTION:
-Tank size [[[MQD“gatfond min.size 1,000 gallons,add 250 gallons for each garbage cylinder or spa/hot tubSystem_|Absorption field with #2 stone_|Totallength"“-Q(1__ft;Each Trench OfSeepagePitwith#3 stone How many:;Size:Alternative System Bed or other type:[Holding Tank System [Total required capacity?tank
siz
7#of tanks
NOTES:1.Alarm system &associated electrical work must be inspected by a Town approved electrical inspectionTBeney;2,We will no longer allow systems to be covered until such time as an as-built plan is received and approvedTheinstalledsystemmustmatchthesepticlayoutonfile—no exceptions
Declaration:Any permit or approval granted which is based upon or is granted in reliance upon any materialrepresentationorfailuretomakeamaterialfactor‘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 SewageDisposalOrdinai
PRINT NAME:Ch c i stogh ¢be l |pare.3-20
SIGNATURE:xy /Lt.DATE:T-3-10eTTt‘Town of Queensbury Building &Code Enforcengat Revised March 2018