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SEPTIC DISPOSAL PERMIT Office Use Only Dare Received ——Tax Map 1D Tax maripPermitNo.=6)= Rees ZED Apeuicant lame Steed)ALG ©PHONE /E-MAl. Aoness Lot HF Avtbor onck Sh aiden SAY fab Sewer Service prove/e-ue ‘ADDRESS:Lo.Lox pees (lent af ME puoneseunn SVE 7B S760 Address Libel CONTAGTPERSONFoRBUILDING&CODESCOMPLIANCE: CrogeDreesLeS Hone 576-74 S00 2. AesipenceIweorwanionuYeLi‘Year Built ‘of bedrooms:X Gallons per bedroom ‘=Total Daily Flow 1980 or older Garbage grinder installed|__Y X_N 1961-1881 ‘Spa or Hot Tub installed|_Y <N 7082 Present 3%FO TDPanceLinrormaTion ‘Topography __XFiatroling Steep slope __%slope ‘Soil Nature —Sand Loam ‘Groundwater ‘Atwhat depin?2 \ ‘Bedrock /Impervious Material ‘At what depth?__/.A ee \ Domestic Water Supply —X Municipal "Well (wel,airsupplytromanysepiasystémabsorptionis__t.) Percolation Test Rate: _7—>per minute perinch (teatfobecompletedby licsheed engineering architect) ‘BnorosenSYSTEM FosNewConsTRUCTION \3 Tank Size (ZZ 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 Total length__Z3 7 tt;Each trench SO"x = ‘Seepage Pit with #3 stone How many:;size. Alternative System Bed or other type? Holding Tank System ‘Total required capacity?Tank size.‘#oftanks __ ‘Motes:1)Alarm systom &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 en As-Bullt plan Is recelved &approved.The installed system must maich the septic system fayout 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.|have read the regulations and agree to abide Town of Queensbury Gantary Sewage Dispose!Ordnance. Date:atheseandallrequirementsofthe Print Name:vee Lec led,“ZO Signature:So ae Date:_s-2F -Zo ‘Town of Queensbury Building &Codes ‘Septic Disposal Permit July 2014