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Office Use Only Permi EP -026 -2025 Permit Fee:$Ewell Invoice #:BasSepticVariance?Yes SEPTIC DISPOSAL PERMIT APPLICATION Town of Qucensbury 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.queensbury.net TaxMapID#:__f0/.7 -2 -2.5 ~ Project Location:_J Swlven Ave Queensbury LY1250Y *Applicant: Name(s):Scott Kowland Mailing Address,C/S/Z:257 W.Mountain Ld Quecnsbury,WY 72504 Cell Phone:_(S/F_)B&3-3976 Land Line:_(} Email:_Srowland 209£©Le Care ¢Primary Owner(s): Name(s):G/oesn FAV eA Mailing Address,C/S/2:_@ SV/vén Ave.Quecosbury,Wy 1260' Cell Phone:_(_57%_)_796EHS land Line:) Email: |i WN 04 zy | TOWN OF QUEEN: BUILDING A CODES jECEIVE O Check if all work will be performed by homeowner only e Contractor:Workers’Comp documentation must be submitted with this application Contact Name(s):__Scot Kowland Contractor Trade: Mailing Address,C/S/Z: Cell Phone:_(5/_)683-3440 Land Line:_(), Email: *Engineer(s): Name(s): Mailing Address,C/S/Z: Cell Phone:_()Land Line:_() Email: Contact Person for Building &Code Compliance:Scott Rowland Cell Phone:_(_S/F)GFF 2YW/0 Land Line:_() Email:_Srow land 209F ©9..C. Septic Application Revised February 2019, RESIDENCE INFORMATION: Year Built [Gallons #of bedrooms:|x gallons per|=total dally low per day bedroom Garbage Grinder Yes|No 1980 orolder|150)2 300 300 Installed?(circle one) 7981-1991 Bo —Spa or Hot Tub Yes|No | Installed?(circle one) 1992-Present|110 PARCEL INFORMATION: Topography JT &Flat Rolling _Steep Slope %Slope _|Soil Nature _X sand loam ___Clay Other (explain:) Groundwater Atwhat depth?—_4/A -Bedrock/Impervious material|Atwhatdepth?A/ADomesticWaterSupply__|_XMunicipal __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 2.00 gallons (min.size 1,000 gallons,add 250 gallons for each garbage cylinder or spa/hot tub System ‘Absorption field with #2 stone|Totallength_y §O ft;EachTrench__5 0 ft. Seepage Pit with #3 stone How many:5 Size: Alternative System Bed or other type:-Holding Tank System Total required capacity?;tank size 3 #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:Scott Rowlen DATE: SIGNATURE:Jei)Yor cl DATE:Ze a Seatic Anoication Revised February 2019