application <.r SEPTIC DISPOSAL PERMIT APPLICATION Offic
e Use Only
742 Bay Road,Queensbury, NY 12804 I i ii.. • k.0. . s? - �?U
P: 518-761-8256 I �J Permit#:
Tax MaplD#: '302 • ( &-- 1 — iZ- p r
rl ! APR 1 f_e2Bt,,Fee: $ 7.cG�'i; Invoice#2S/U
I l Hi lb
7 No
Project Location: (JI i� Septic Variance? Yes
Primary Owner(s) Kerr 1 (Jr e
Mailing Address 43 Ri dt v, HA) Pr.
Phone & Email S I IC— 53 -0-1) 1'
Installer/Builder I R) Sep f i C
Mailing Address #Z... Lower Jrnrr(r• 54. Qt^F;er logo
Phone & Email r�-I g_1 CH
�Ury y
Engineer 1
Mailing Address
Phone & Email
Contact Person for Building & Code Compliance: C-k^115 8e I( Phone: 51 3 61-2 I b.1
RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms X gallons per = total daily flow
per day bedroom Garbage Grinder Yes No/
1980 or older 150 Installed? (civ-cle one)
1981-1991 130 Spa or Hot Tub Yes Np
) — Installed? (circle one)
1992-Present no 3 �J n 33q
PARCEL INFORMATION:
Topography lat Rolling Steep Slope %Slope
Soil Nature Sand Loam Clay Other
Groundwater At w t depth?
Bedrock/Impervious material At hat 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 FORW CONSTRUCTION:
Tank size i t�( �`ga Ions` (min. size 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:
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. 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: ( I r I)t°p n t r fl ) DATE:Lf—I O-1 O
SIGNATURE: diti
DATE: 4—I( —DX)
Town of Queensbury Building&Code Enforcement
Revised March 2018