applicationSEPTIC DISPOSAL PERMIT APPLICATION
742 Bay Road,Queensbury,NY 12804Tomfs":518.761.8256 www.queensbury.net
Office Use Only
Permit SEP -O2\4-2020
‘Tax Map ID #:301.12-3-63 Permit Fee:$127 ;invoice #:_256%
Project Location:10 ZENAS DRIVE Septic Variance?Yes __No
Primary Owner(s)_|PATRICK GAUTIER
r
Mailing Address ‘10 ZENAS DRIVE,QUEENSBURY,NY INECEIWVED!
Phone &Email RK ITTInstaller/Builder|SANITARY SEWER SERVICES UT |MAY 26 ia,|UyIMailingAddressLUZERNEROAD,QUEENSBURY NY 2 YT
Phone &Email 5187969760 oe |Engineer TOM CENTER
Mailing Address 73 SHERIDAN STREET,GLENS FALLS,NY 12801
{Phone &Email TCENTER36@YAHOO.COM
Contact Person for Building &Code Compliance:GEORGE DRELLOS Phone:5187963760
RESIDENCE INFORMATION:
Year Built|#ofbedrooms|X gallons per bedroom_|=total daily flow||Garbage Grinder Yes
1980 or older Installed?(circle one)
"7981-1991 ‘Spa or Hot Tub Yes |@lo)
Installed?(circle one)1992-Present 3 110 330
PARCEL INFORMATION:
Topography ¥_Flat Rolling Steep Slope %Slope
Soil Nature Sand Loam Clay Other
‘Groundwater ‘At what depth?DEEPER THAN 6
Bedrock/Impervious material|At what depth?NONE
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 EXISTING 1000 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:20X30 FT BED
Holding Tank System Total required capacity?;tank size ;#of tanks
NOTES:.Alarm system &associated electrical work must be inspected by yy 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.
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 requirement
Disposal Ordinance.
PRINT NAME:_GEOBGE DRELLOS
SIGNATURE:#
‘Town of Queensbury Building &Code Enforcement
its of the Town of Queensbury Sanitary Sewage
DATE:__8/23/2020
Revised February 2017