application@&SEPTIC DISPOSAL PERMIT APPLICATION Office Use Only742BayRoad,Queensbury,NY 12804
P:518-761-8256 www cusensdury.noe Permit #:SEC -Q\\n4-BLO
Permit Fee:$F invoice #:25 Vy
Project Location:Xd 34 WE tnd Septic Variance?___yes we[Primary Owner(s)|Erman Leffler re|Mailing Address Wd oe —_ta ’
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Engineer|Mailing Address
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RESIDENCE INFORMATION:_Year Built |Gallons |#of bedrooms|X gallons per]=total daily flow |oe||per day |bedroom Garbage Grinder Yes|No,1980 or older |150 Installed?(circle one)|_Tieai-is91 Bo |[Spa orHotTub Ty
Tax Map ID
Installed?(circle one)1992-Present |110 4 |GY 9 |PARCEL INFORMATION:|Topography I fat Rolling Steep Slope %Slope|Soil Nature Sand loam Clay Other -|Groundwater At what depth?
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_Bedrock/Impervious material|At jrhat 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 [[CQq_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 SQ)ft;Each Trench _S()ft.|L Seepage Pit with #3 stone How many:_Size:
LT Alternative System Bed or other type:_--|L_|Holding Tank System|Total required capacity?j tank size Hof tanksNOTES:1.Alarm system &associated electrical work must be inspected by a Town approved electrical inspectionS8ency;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
:Any permit or approval granted which is based upon or is granted in reliance upon any materialj_bresentation or failure to make a material factor circumstance known by or on behalf of an applicant,shall be votd,|have read the regulations and agree to abide by these and all requirements of the Town of Queensbury Sanitary SewageDisposalOrdinance,
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