applicationSEPTIC DISPOSAL PERMIT APPLICATION|office Use Only
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.netTown
Tax Map ID #:301.7-1-30
permit:
SEP-016|-
R020
Permit Fee:$“79 —_;invoice #:25/3
Project Location:12 BUENA VISTA AVENUE Septic Variance?__Yes__No
Primary Owner(s)ELIZABETH BAROUDI
Mailing Address 12 BUENA VISTA AVENUE,QUEENSBURY,NY
Phone &Email EE Ip)
Installer/Builder SANITARY SEWER SERVICES
Mailing Address LUZERNE ROAD,QUEENSBURY NY
|
Phone &Email 5187963760 oO
Engineer TOM CENTER
Mailing Address ‘73 SHERIDAN STREET,GLENS FALLS,NY 12801
Phone &Email ‘TCENTER36@YAHOO.COM
Contact Person for Building &Code Compliance:GEORGE DRELLOS Phone:5187963760
RESIDENCE INFORMATION:
Year Bi #of bedrooms|Xgallons per bedroom_|=total daily flow||Garbage Grinder Yes
7980 or older Installed?(circle one)
7981-1991 Spa or Hot Tub Yes |@o
Installed?(circle one)1992-Present 4 110 440
PARCEL INFORMATION:
‘Topography PA Steep Slope %Slope
Soil Nature Sand Loam Clay Other
Groundwater At what depth?DEEPER THAN 6°
Bedrock/impervious material|At what depth?NONE
Domestic Water Supply _/Municipal __Well (if well,water supply from any septic system absorption is__ft.)
Percolation Test Rate:1 per minuteper inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size |1250 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:
Alternative System Bed or other type:20X30 FT BED
Holding Tank System Total required capacity?3 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.
PRINT NAME:GEORGE DRELLOS
SIGNATURE:
—DATE:_4/16/2020
Town of Queensbury Building &Code Enforcement Revised February 2017