applicationSEPTIC DISPOSAL PERMIT APPLICATION Office Use Only
Town of
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net Permit #:_SEP-DD 04.-JOVO
‘Tax Map ID #:301.6 Permit Fee:$T>"_;invoice #:266
Project Location:12 HELEN DRIVE Septic Variance?_Yes__No
Primary Owner(s)|MATTHEW AUTHIER
Mailing Address 12 HELEN DRIVE,QUEENSBURY,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
RESIDENCE INFORMATION:
Phone:5187963760
Year Built|#ofbedrooms|Xgallons per bedroom_|=total daily flow||Garbage Grinder Yes [(®o)
1980 or older Installed?(circle one)
7981-1991 ‘Spa or Hot Tub Yes |(@o)
Installed?(circle one)
1992-Present 4 110 440
PARCEL INFORMATION:
Topography Steep Slope %Slope _
Soil Nature 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 absorption is__ft.)
Percolation Test Rate:15"per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size |1250 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 ft;Each Trench ft.
Seepage Pit with #3 stone How many:3;Size
Alternative System Bed or other type:20X30 FT BED
Holding Tank System Total required capacity?;tank size 3 #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 whict 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 al
Disposal Ordinance.
PRINT NAME:GEORGEDRELLOS
by these and all requirements of the Town of Queensbury Sar
DATE:
SIGNATURE:Ye Za Le
‘Town of Queensbury Bulding &Code Enforcement
ry Sewage
5/18/2020
Revised February 2017