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applicationfice Use Only Oat 20.SEPTIC DISPOSAL PERMIT APPLICATION permit rears ott 4TnofChenerySepticVariance?Yes 742 Bay Road,Queensbury,NY 12804 161-8256 www.queensbury.net ‘Tax Map ID #:308.14-1-52 Project Location:Lot #12 &14 Forest Park *Applicant: Name(s):Stone Installations Mailing Address,C/S/Z:4305 Rt.50 Saratoga,NY 12866 Cell Phone:(518)232-6707 Land Line:(518)584-1048 Email:dean@stoneindustries.com «Primary Owner(s): Name(s):RHP Properties Mailing Address,C/S/2:183 Pitcher Rd.Queensbury,NY 12804 Cell Phone:(NA)Land Line:(518)745-7776 Email:forestpark@rhp-properties.com O Check if all work will be performed by homeowner only «Contractor:Workers’Comp documentation must be submitted with this application Contact Name(s):Stone Installations Contractor Trade:Septic Systems Mailing Address,C/S/Z:4305 Rte.50 Saratoga,NY 12866 Cell Phone:(518)232-6707 Land Line:(518)584-1048 Email:dean@stoneindustries.com *Engineer(s): Name(s):Ryan K.Riper P.E. Mailing Address,C/S/2:225 Ruggles Rd.Saratoga,NY 12866 Cell Phone:(518)817-0099 Land Line:(518)817-0099 Email:ryanriper@rkengineering.us Contact Person for Building &Code Compliance:Dean Burdick Cell Phone:(518)232-6707 Land Line:(518)584-1048 Email:dean@stoneindustries.com Septic Application Revised February 2019 RESIDENCE INFORMATION: Year Built [Gallons|#of bedrooms:|X¢allons per|=total daily flow perday |6 bedroom 660 1980 orolder|150|cickartaphere|Clickortap|Clickortap «here to enter|enter text. sont Garbage Grinder Yes|NoIIT|80 |Gckoruoher|clekortan|Gickor ta heres Installed?(check one)|O|62oentertexretoenter|enter text text ‘Spa or Hot Tub Yes|Noieeetromm|110 [6 40 £60 Installed?(check one)||& PARCEL INFORMATION: Topography ®FlatRolling _O Steep Slope %Slope Soil Nature Sand Ooam _Oclay Other (explain:) Groundwater ‘At what depth?None Bedrock/impervious material|At what depth?None Domestic Water Supply ©Municipal _C Well if well,water supply from any septic system absorption is__ft.) Percolation Test Rate:__2__per minuteper inch (test to be completed by licensed engineer/architect) PROPOSED SYSTEM FOR NEW CONSTRUCTION: Tank size 1,000___gallons (min.size 1,000 gallons,add 250 gallons for each garbage cylinder or spa/hot tub ‘System Gravelless Chambers ARC-24__|Total length _220,;Each Trench _$5__ft. ‘Seepage Pit with #3 stone How many:5Si ‘Alternative System Bed or other type: Holding Tank System Total required capacity?j tank size 7 #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.|have read the regulations and agree to abide by these and all requirements of the Town of Queensbury Sanitary Sewage Disposal Ordinance. PRINT NAME:Dean Burdick SIGNATURE:Dean J.Burdick DATE:April 2,2020 Septic Application Revised February 2019,