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application
Office Use Onh Permit #:SP-O\0 = Permit Fee:$|2>_;Invoice #:Z=>2] Septic Variance?Yes _«No SEPTIC DISPOSAL PERMIT APPLICATION Fun of Queensbury 42 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.queensbury.net ‘Tax Map ID #:4.9-1-30 Project Location:—]\.Cstse ReeX C dou ©Applicant: Name(s):ye Go MC Mailing Address,C/S/2;SC (OK CaeKSCON. Cell Phone:_(Sva ISSR ———land Line:(SG)S45~SRcQEmail:__@uicc oc \yaer 2 Coon ©Prima mer(s):=—_— Name(s):<2 a Secs Vy ere seAE Mailing Address,C/S/Z:_—=3 =Cell Phone:_()a land Line:_()aeFails O Check if all work will be performed by homeowner only ©Contractor:Workers’Comp documentation must be submitted this application Contact Name(s):A\snotty)Som Contractor Trade: Mailing Address,C/S/Z: Cell Phone:_() Email: ©Engineer(s): Name(s): Mailing Address,C/S/Z: Cell Phone:_()Land Line:_() Email: Contact Person for Building &Code Compliance:SASS(Ree VeoCellPhone:_()Land Line:_() 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 1 1980 or older|}150 Installed?(circle one)to] = ‘Spa or Hot Tub Yes-{No_18h I84 30 Installed?(circle one)hey 11992-Present|110 PARCEL INFORMATION: Topography Flat Rolling Steep Slope %Slope Soil Nature __Sand loam Clay ___Other (explain:) ‘Groundwater At what depth? Bedrock/Impervious material|At what depth? Domestic Water Supply Municipal __Well if well,water supply from any septic system absorption is___ft.) Percolation Test Rate:per minute per inch (test to be completed by licensed engineer/architect) PROPOSED SYSTEM FOR NEW CONSTRUCTION: Tank size 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 Each Trench ft, Seepage Pit with #3 stone How many:;Size: Alternative System Bed or other type: Holding Tank System Total required capacity?;tank size 5 Ht 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. ort name:A ps ees \denoncw pate:A-2\-2C 5 Septic Application Revised February 2019