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Office Use Only =220DSEPTICDISPOSALPERMITAPPLICATIONInvoice#:ZAG 2— Yes NoSepticVariance? Road,Queensbury,NY 12804 P:518-761-8256 www.queensbury.net Tax Map ID #:301.9-1-39 Project Location:34 Western Reserve Trail \ ¢Applicant: Name(s):Manuel (Mickey)S.Orta Mailing Address,C/S/Z:34 Western Reserve Trail Queensbury,NY 12804 Cell Phone:(59 _)432 -1994 Land Line:_() Email;_flexey 2014 @ [Clow Cam ©Primary Owner(s): Name(s):Same as applicant Mailing Address,C/S/Z: Cell Phone:_()Land Line:_() Email:, O Check if all work will be performed by homeowner only Contractor:Workers’Comp documentation must be submitted with this application Contact Name(s):Cooks Septic Service Contractor Trade:Installation Mailing Address,C/S/Z:84 Ralph Road Lake Luzerne,NY_12846 Cell Phone:_()land Line:_(518 _)696-4500 Email: ©Engineer(s): Name(s):Hutchins Engineering PLLC Mailing Address,C/S/Z:169 Haviland Road Queensbury,NY_12804 Cell Phone:_()land Line:_(_518__)745-0307 Email:_thutchins@hutchinsnegineering.com Contact Person for Building &Code Compliance:Tom Hutchins /Dan Cook Cell Phone:_()Land Line:(518 _)745-0307 /518-696-4500 Email: Septic Application Revised February 2019, RESIDENCE INFORMATION: Year Built [Gallons|#of bedrooms:|X gallons per|=total daily flow per day bedroom Garbage Grinder Yes (o)| 7980 or older|150 Installed?(circle one) ‘Spa or Hot Tub Yesteacher2Installed?(circle one)1992-Present|110 4 110 440 PARCEL INFORMATION: Topography X_Flat Rolling ‘Steep Slope %Slope Soil Nature:X sand loam __Clay X Other (explain:Silt ) Groundwater At what depth?presumed seasonal highwater table at 55" Bedrock/Impervious material|At what depth?_greater than 77" Domestic Water Supply X Municipal___Well (if well,water supply from any septic system absorption is___ft.) Percolation Test Rate:_8-10 per minute per inch (test to be completed by licensed engineer/architect) PROPOSED SYSTEM FOR NEW CONSTRUCTION:&Xling concrete TankTo be pumped,inspected,and reused W suitable Tank size 1,250 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 ft. ‘Seepage Pit with #3 stone How many:;Size: [Aitemnetive-speter-Bed|Bed or other type:15'x 45" Holding Tank System Total required capacity?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. print Name:Manuel S.Orta pate:_J/O%hyyaL { SIGNATURE:MDS pare:Z/s/ve Septic Application Revised February 2019