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Office Use Only 002F Permit #SEP BP7-2050 Permit Fee:$_“75.00;Invoice #:J39¢ Septic Variance?Yes __L No SEPTIC DISPOSAL PERMIT APPLICATION 742 Bay Road,Queensbury,NY 12804 P:518-761-8256.www.queensbury.net Tax Map 1D #;789.1542 Project Location:52 Nolan Camp Road *Applicant: Name(s):Jane Nolan Barton &5 Siblings Mailing Address,C/S/Z:445 Ridge Road Queensbury,NY_12804 Cell Phone:_()Land Line:_() Email: ©Primary Owner(s): Name(s):_same as applicants Mailing Address,C/S/Z: Cell Phone:_()Land Line:_() Email: Ci Check if all work will be performed by homeowner only *Contractor:Workers’Comp documentation must be submitted with this application Contact Name(s):_TBD Contractor Trade: Mailing Address,C/S/Z: Cell Phone:_()Land Line:_() Email: «Engineer(s): Name(s):Hutchins Engineering PLLC Mailing Address,C/S/Z:169 Haviland Road Queensbury,NY_12804 Cell Phone:_()Land Line:(518 __)745-0307 Email:_thuthcins @hutchinsengineering.com Contact Person for Building &Code Compliance:_Hutchins Engineering PLLC Cell Phone:_()_Land Line:(518 __)745-0307 Email:_thuthcins @ hutchinsengineering.com Septic aplication Revised February 2019 RESIDENCE INFORMATION: Year Built Gallons|#of bedrooms:|X gallons per|=total daily flow per day bedroom Garbage Grinder Yes|No 1980 or older|150 4 total 110 440 Installed?(circle one) 7981-1991|130 ~‘Spa or Hot Tub Yes|No Installed?(circle one) 1992-Present|110 PARCEL INFORMATION: Topography Flat Rolling Steep Slope ¥_%Slope _5-8% Soil Nature _¥Sand ___loam ___Clay __Other (explain:) Groundwater At what depth?greater than 62" Bedrock/Impervious material|At what depth?greater than 62" [Domestic Water Supply LAKE|__Municipal __Well (if well,water supply from any septic system absorption is___ft.) Percolation Test Rate:_4:45 per minute per inch (test to be completed by licensed engineer/architect) PROPOSED SYSTEM FOR NEW CONSTRUCTION: Tank size 1.250 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:Size: _Alternative System Bed or other type:12’x 31'Presby Absorption Bed CE Holding Tank System Total required capacity?tank size ;Hof 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 plan 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.|have read the regulations and agree to abide by these and all requirements of the Town of Queensbury Sanitary Sewage Disposal Ordinance. (AGENT pRINT NAMES DHOWHAS HUTS PC er SIGNATURE:AQSS DATE:2fisjzo Septic Application Revised February 2019,