application •
Office Use Only
b- SEPTIC DISPOSAL PERMIT APPLICATION Permit#: 2.0?.-_�
Permit Fee: $ rj ; Invoice#: 9 b
1. l�l pcctis�,- Septic Variance? Yes No
4, 742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net
Tax Map ID #:
Project Location: i p <7 re_.r ,,,_,„hd (1, , -,.) - E,,r ,,-i-
• Applicant: -
Name(s): 119 e . n -12..Ii,:..f;c.,4-7
Mailing Address, C/S/Z: y-3ci Af--c , 5-0 34;1'«-f foie. Spy,:Idci y I Al. K I 24%E,L
Cell Phone: ( ci ) ,,, 32- - L 7c-v-7 Land Line: ( 5'2 e ) t7 4 1 - /& •?-
EmaiI: de-c; &. 51 ( ,-, e . vt ,L. t-r & ,' s , C 0 1-2-1
• P irr.ary Owner(s):
Name(s): ii-it2 ?ecpc_rj-le..s
Mailing Ads'ress, C/S/Z: f j P'. f- <_.'- 124). �,.mac, sL-:cf-,7, V / I z €, & t
Cell Phone: ( 5 /c`? ) -7ti-c- 7 7 71. Land Line: ( )
Email: - a—e,yt)C-nK _ % f` ' i> r->re., p c r7;e-> . c..c;6,---t
❑ Check if all work will be performed by homeowner only
• Contractor: Work s' Comp documentation must be submitted with this application
Contact N2 me(s): mac.:.. 15..,�c,,.ace S , ,cr. L.-.l -3 « , i .-_ 11.-. i _-.S
Contractor Trade: ✓Ge 1-,G ,S r, f-G---- s ,
Mailing Address, C/S/Z: i f- ; �-+
! '-c. �.��% ,_5(f..r4..)--- ,; i ,,ti•I' /Z /7 i
Cell Phone: I, 5-"/ ) Z. 3L - Z 1 -7 Land Line: _( 5-ig ) j u p'- /'- Lf-t,
Email: de Cr—..,,� s--"t. .,7� : ,r".C),.3-t--.^, Gf - G -a-.
Name(s): 4c,-- ,-..„,
/ , kc.:1....:‘,„, , ,,c,c..7-, ....*
Mailing Address, C/S/Z: z.2... K,, .t cd c_3 r S`'"g-f 4 4tz, it /' / L E.L
Cell Phone: _( ) (Si 7 G u (j 4/ Land Line: _( )
Email: ^, ?c.."' tip rk-d-r: . vi r r 4 i.�
r r � - Y y s
Contact Person for Building & Code Compliance: r<<. v•rc/..-/C.:
Cell Phone: (5 A ) 2 5Z_ /70-7 Land Line: _( �''/f;) 5G =,0/-,_,.,
Email: efr,x,.,.,ej S f��.-,r , :-i c�J y -i--,-, c s , G�
Septic Application Revised February 2019
' RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms: X gallons per =total daily flow _
per day bedroom Garbage Grinder Yes i
1980 or older 150 Installed? (circle one)
1981-1991 130 Spa or Hot Tub Yes )'N'
Installed? (circle one)
1992-Present 110 ' 3 3( 3
PARCEL INFORMATION:
Topography Flat Rolling Steep Slope %Slope
Soil Nature Sand Loam _Clay _Other(explain:
Groundwater At what depth? / r
Bedrock/Impervious material At what depth? stt L��� I.NCER ?Ro4 /0'1s
Domestic Water Supply Aej Municipal _Well (if well, water supply from any septic system absorption is ft.)
Percolation Test Rate: .T" per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size 4.0c, 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 /f 0 ft.; Each Trench 5 s ft.
Seepage Pit with#3 stone How many: ;Size:
Alternative System Bed or other type:
Holding Tank System Total required capacity? ;tank size ; #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 olan 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. I have read the regulations and agree to abide by these and all requirements of the Town of Queensbury
Sanitary Sewage Disposal Ordinance.
PRINT NAME: �'k✓t t�/'v'�/� DATE: "LCZt-'
SIGNATURE: 1 _ DATE: -
Septic Application
Revised February 2019