applicationSEPTIC DISPOSAL PERMIT APPLICATION Office Use Only
742 Bay Road,Queensbury,NY 12804 ._*P:518-761-8256 www.queensbury.net Permit #:+o\SF-2029
Tax Map ID #:302.14-3-17 Permit Fee:$4“;invoice #:2505
Project Location:40 PARKVIEW AVENUE Septic Variance?Yes No
Primary Owner(s)_|SUSAN DEAN
Mailing Address 40 PARKVIEW AVENUE,QUEENBSURY NY |
|Phone &Email
Installer/Builder SANITARY SEWER SERVICES
Mailing Address LUZERNE ROAD,QUEENSBURY NY
Phone &Email 5187963760
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 Built|#ofbedrooms|X gallons per bedroom_|=total daily flow||Garbage Grinder Yes
1980 or older ]Installed?(circle one)
1981-1991 ‘Spa or Hot Tub Yes |@
Installed?(circle one)1992-Present 3 110 330
PARCEL INFORMATION:
Topography 7 Flat Rolling 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 absorptionis__ft.)|Percolation Test Rate:1'-5'__per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size |1000 gallons (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?;tank size #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:THOMAS CENTER,PE DATE:__04/08/2020
SIGNATURE:_~Low aTownofQueensburyBuilding&Code Enforcement Revised February 2017