application;
°.SEPTIC DISPOSAL PERMIT
ba 4/28/2029:
TaxMarip2.34 1-1-Ob
LOCATIONOF
INSTALLATION S564 Reon Hi
APPLICANT Devel SONN Fone Faee
‘ADDRESS b4 Hoow Hill Rel
InstauenBuuver:Streights Sephe Service pronesewh SIP )H8O-YB83S
ADDRESS:12 Sissos Bd Sooth Glens hulls NY (2803
Onmen “Tack “S_Stred ght Prone /E-wah S1%'744-9373
‘Address Sam &
&SOMPLIANCE:‘PHONE:
[RESIDENCE INFORMATION
‘Year Built #of bedrooms:X Gallons per bedroom =Total Daily Flow
1980 or older Garbage grinder installed|__Y «N
1981-1991 ‘Spa or Hot Tub installed _—Y _/N
1902-Present|>nes 220PARCELINFORMATION
Topography __-Flatroling Steep slope ___%slope
Soil Nature Sand ——Loam ——Clay _——Other
Groundwater At what depth?_—__—
Bedrock Impervious Material what dep?Domestic Water Supply Municipal _1—Well (if well,water supply trom any septic system absorption is LO Ort)
Percolation Test Rate:per minute per inch (test to be completed by licensed engineering /architect)
‘ProposedSYSTEM
FORNEwCONSTRUCTION
Eusx _Vowuramon)
Tank Sze GyeK|LESS gas (ini siz 1000 gallos,add 250 gallos to si lor each garbage andor of spa or Pat)
System Type ‘Absorption field with #2 stone oe eex‘Seepage Pt with #@ stone How many:
Alternative System Bed or other type?|
Hoiing Tank Sytem Total required capacity?____Tankize Foftanks
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 fle —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
agre0 fo abide bythose and al reguirgments ofthe Town of Queensbury Sanitary Sewage Disposal Ordinance.
Print Name:hee CEO Date:4—4P ~2020
Signature:2S Lun Date:aP-JOZO
‘Town of Queensbury Building &Codes.‘Septic Disposal Permit July 2014