applicationSEPTIC DISPOSAL PERMIT
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ADDRESS 13 CKorlton GP Qseenshor,NY 13804
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‘ADDRESS:TW Sissern Rd Scoth Glens falls NY 12803
owner Jack _Streight Prone wh SiB)V4 I 373
Address Seme
CONTACTPERSONFORBUILDING&CODESCOMPLIANCE:
PHONE.
RESIDENCE
INFORMATION -
Year Built *#of bedrooms X Gallons per bedroom|=Total Daily Flow
1980 or older Garbage grinder installed|__Y JN
1981-1991 ‘Spa or Hot Tub installed|__Y AV
1992-Present Q Us 339PARCELINFORMATION
Topography Fiat roling Steep slope ___%slope
Soil Nature Sand Loam Clay __Other
Groundwater ‘At what depth?,
‘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 engineering /architect)
New Cons:
Tank Size 1==S gallons (minimum size 1,000 gallons,add 250 gallons to size for each garbage grinder or spa or hot tub)
‘System Type ‘Absorption field with #2 stone__|Totallength 13>fh;Each trench SQ x 3
‘Seepage Pit with #3 stone How many:;size
‘Aitemative System Bed or other type?
Holding Tank System Total required capacity?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 &approved.The installed system must match the septic system
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 know by or on behalf of an applicant,shall be void.I have read the regulations and
agree to abide by these and all sof the Town of Queensbury Sanitary Sewage Disposal Ordinance.
Print Name:nS Apesele—Date:PS =2520
Signature:(Arar Date:HagP—-ROVO
Town of Queensbury Building &Codes ‘Septic Disposal Permit July 2014