Application@&SEPTIC DISPOSAL PERMIT APPLICATION Office Use Only
oe monomnse rants EEP-05602020 _
Permit Fee:§V7 5 invoice #:2%
Septic Variance?Yes No
[Mailing Address |
JV So sod
-Phone &Email re Wyor o|Installer/Builder TR5SSette_-reetiess |Lowe Warren St.Ouyetasbacy NYILQOE[Phone &Email 15$=19-3 194 cell CngecngMYLS—|Engineer ————Mailing Address ~eee fE ny
Phone &Email In]say oggensfyPhone:5 1f~36l-$eSFegEENSBURY
F
n :BULDINGR CODES.|Gallons #of bedrooms |X gallons per|=totaldailyflow_—_per day bedroom ||Garbage Grinder Yes WY|1980 or older|150 |
Installed?(circle one)|_[q9a1-1991 B30 T
I
—||Spa or Hot Tub Yes|Ni
=(Installed?(circle one)||_|/1992-Present
|
no|PARCEL INFORMATION:
a [To HO|Topography [Yet Rolling Steep Slope %SlopeSoilNature
-Sand ___Loam Clay ___Other[Groundwater At what depth?__-||Sedrock/impervious material |At what depth?_Domestic Water Supply _—Municipal ___Well (if well,water supply from any septic system absorption Is ft)|Percolation Test Rat per minute per inch (test to be completed by licensed engineer/architect)|PROPOSED SYSTEM FOR NEW CONSTRUCTION:
7TanksizeBetongallons(min.size 1,000 gallons,add 250 gallons for each garbage cylinder or spa/hot tubfe q|System
___|
Absorption field with #2 stone_|Total length D7)0 __fts Each Trench __ft.__|_Seepage Pit with #3 stone |How many:_
Size:
7 ZLAlternativeSystemBedorothertype:-_|Holding Tank System Total required capacity?;tank size
_5 #of tanks
NOTES:1.Alarm system &associated electrical work must be inspected by a Town approved electrical inspectionagency;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(ePresentation 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 SewageDisposalOrdinanc;
ronan Ct ge ome 424-20
SIGNATURE:
ZL
CATE:4929LE;i‘Town of Queensbury Building Mode Enforce Revised March 2018