applicationSEPTIC DISPOSAL PERMIT APPLICATION Office Use Only—742 Bay Road,Queensbury,NY 12804 t=OmnnOwe’e 518-761-8256 vin qusonsbucy net Permit:
SEP~0286-207
Tax Map ID #:Permit Fee:$%5~_;invoice #:oDProjectLocation:_|Grant Ave Ebvasen|seoticvariance?ves No|Primary Owner(s)|Car|4 ial u -|Mailing Address
Phone &Email
Installer/Builder IR3SenMailingAddressToons—BgeFCEngineereehet———Malling Address TAY (farePhone&Email [SiETYLOL ES
1g &Code Compliance:C ‘S
RESIDENCE INFORMATION:
Contact Person for Buil
Year Built|Gallons|#of bedrooms|X gallons per|=total daily flow —=per day bedroom Garbage Grinder Yes|Ni1980orolder}150~|[installed?(circle one)1981-1991|130 [ie Sle.we vee y|1992-Present|110 G Ul Q Gy 0
stalled?(circle one)|PARCEL INFORMATION:
Topography i/plat Rolling Steep Slope %SlopeSoilNatureSandLoam,Clay Other|Groundwater At what depth?
Bedrock/Impervious material|At what depth?_|Domestic Water Supply __|_\/Municipal___Well if well,water supply from any septic system absorption is __ft)Percolation Test,Rate:er minute per inch (test to be completed by licensed engineer/architect)PROPOSED SYSTEM FOR NEW.CONSTRUCTION:_
Tank size |[V5O gallons (min.size 1,000 gallons,add 250 gallons for each garbage cylinder or spa/hot tubSystem|Absorption field with #2 stone_|Total length ft;Each Trench ftLSeepagePitwith#3 stone How many:;Size:Alternative System Bed or other type:_%XSK _|Holding Tank System Total required capacity?_
;tank size j#oftanksNOTES:1.Alarm system &associated electrical work must be inspected by a Town approved electrical inspectionSeency;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,
‘ny permit or approval granted which is based upon or is granted in reliance upon any materialoFfailuretomakeamaterialfactorcircumstanceknownbyoronbehalfofanapplicant,shall be void,|have read the regulations and agree to abide by these and all requirements of the Town of Queensbury Sanitary SewageDisposalOrdinance.
PRINT NAME:Christo der Be (|vate (0-20
SIGNATURE:Gil DATE:&lO)9