application Office Use Only
SEPTIC DISPOSAL PERMIT APPLICATION Permit#: ; ' ??
Permit Fee: $ Invoice
#:
Town of cLce,sbuN Septic Variance? Yes No
742 Bay Road,Queensbury,NY 12804
P: 518-761-8256 www.queensbury.net
Tax Map ID #: 23 '4 - SOB. - I - -114
Project Location: Q9 l. ,1 d OLV,e,n5bilvq
• Applicant: Er(Name(s): ►� �0 l.tr\+-
Mailing Address, C/S/Z: 2-
Cell Phon : c�18 )� ? ' t47 Land Line: (
Email: �OQY f L Din l° mCLI I COPY)
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• Primar Owners :
Name(s): I—
Mailing Address, C/S/Z: Z, C ,
Cell Phon : _( _) 1 - Land Line: _( )
Email:eaM QS Qo3 e arno L.)3( m
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Check if all work will be performed by homeowner only
• Contractor: Workers' Comp documentation must be submitted with this application
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z: n
Cell Phone: _( ) Land Line:
Email: vow 9 2(123
• Engineer(s): TOWN OF QUEENSBURY
BUILDING&CODES
Name(s):
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: _(
Email:
Contact Person for Buildin C e omplianceN 1flDLCr
Cell Phone: )7 - Land Li : _(
Email: 1 ..,e,�,.�su Q-nal C,OM
Septic Application 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 Installed? (circle one)
1981-1991 130 Spa or Hot Tub el) No
Installed? (circle one)
1992-Present 110
3 3
PARCEL INFORMATION:
Topography k Flat Rolling Steep Slope %Slope
Soil Nature ' Sand _Lo m Clay _Other(explain:
Groundwater At what depth? /rn/-
Bedrock/Impervious material At what 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 FOR NEW CONSTRUCTION:
Tank size 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 Z.o' ft.; Each Trench �L) ft.
Seepage Pit with#3 stone How many: nc� ; Size:
Alternative System Bed or other type: "It-
Holding Tank System Total required capacity? r/%r ; 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 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. 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: �1 DATE: 5( )1IZv
SIGNATURE: 7�P�i ,4„----) DATE: S f I% ZC)
Septic Application Revised February 2019