applicationTax Map ID #:
SEPTIC DISPOSAL PERMIT APPLICATION
742 Bay Road,Queensbury,NY 12804
P:518-761-8256.wo.cu
Office Use Only
Permit #:_SEP -WYS-2070
Permit Fee:$T>__;invoice #:2-19
Project Location:LK Meee F Yes NoSepticVariance?vk
|Primary Owner(s)
Mailing Address
Phone &Email
Installer/Builder
Soann_Dvicit if
ay
Mailing Address a=f
<_,ytEre.nee qe }|Phone &Email
Engineer TIrs |‘|
Mailing Address
|Tul I
-
|Phone &Email -
;
[
Contact Person for Building &Code Compliance:1h})-.|RESIDENCE INFORMATION:_
-]
Year Built’|Gallons|#of bedrooms|X gallons per --[per day bedroom |Garbage Grinder1980orolder|150 Installed?(circle one)|1981-1991 130 ‘Spa or Hot Tub=‘a[Installed?(circle one)1992-Present
|
110
|4 Ld 0|PARCEL INFORMATION:
Topography (Zt Rolling _Steep Slope %SlopeSoilNature/Sand loam Clay Other |Groundwater
Domestic Water Supply
Percolation Test
PROPOSED SYSTEM FO![Tank size
System|Bedrock/impervious material
At what depth?
-_—Atyhat depth?
_7Municipal__Well (if well,water supply from any septic system absorption is__Rate:Per minute per inch (test to be completed by licensed engineer/architect)
[EW CONSTRUCTION:
[OE FatiAs\min.size 1,000 galions,add 250 gallons for each garbage cylinder or spa/hot tub
|Absorption field with #2 stone |Total length “OO ft;Each Trench__5 ft.-Seepage Pit with #3 stone
_How many:_s Size:
Alternative System
Holding Tank System
|Bed or other type:Total required capacity?_tank size 5 #of tanks
NOTES:1.Alarm system &associated electrical work must be inspected by a Town approved electrical inspectionagency;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
Declaratic
representation or failure to
have read the regulations and agree to abide by
Disposal Ordinance.\
PRINT NAME:_
SIGNATURE:__
‘Town of Queensbury Building &Code
exceptions.
#Any permit or approval granted which is based upon or is granted in reliance upon any materialmakeamaterialfactorcircumstanceknownbyoronbehalfofanapplicant,shall be void.|
y these and all requirements of the Town of Queensbury Sanitary SewagetohBellom2b10
DATE:YY f-10
Enforcemen Revised March 2018