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Office Use Only SEPTIC DISPOSAL PERMIT APPLICATION|Permit#_5EP-O-n2>- 202.0 Permit Fee:$_*5 _;Invoice #: Septic Variance?Yes NoTownofQucent 1742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.queensbury.net Tax Map ID #:_225-12-1-35BeProjectLocation:®Mason Road -Cleverdale ©Applicant: Name(s):James &Mary Ann Finnecy Mailing Address,C/S/Z:85 Mason Road,Queensbury,NY 12804 Cell Phone:_()Land Line:_() Email:_bfinnecy@gmail.com -Bob Finnecy (Agent) ¢Primary Owner(s): Name(s):same as applicants Mailing Address,C/S/2: Cell Phone:_()Land Line:_() Email: C1 Check if all work will be performed by homeowner only *Contractor:Workers’Comp documentation must be submitted with this application Contact Name(s):Crandall Excavating,Inc. Contractor Trade:Excavating Mailing Address,C/S/Z:63 Woodchuck Hill Road,Lake George,NY 12845 Cell Phone:_(518__)470-4694 Land Line:(518 _)_793-0431 Email:chriscrandalldigs@gmail.com e Engineer(s): Name(s);Hutchins Engineering PLLC Mailing Address,C/S/Z:169 Haviland Road Queensbury,NY 12804 Cell Phone:_().Land Line:(518 _)745-0307 Email:iwdobie@hutchinsengineering.com Contact Person for Building &Code Compliance:Hutchins Engineering PLLC Cell Phone:_()_(518 __)745-0307 Email:lwdobie@hutchinsengineering.com ‘Septic Anplication Revised February 2019, RESIDENCE INFORMATION: Year Built Gallons #of bedrooms:|X gallons per|=total daily flow per day bedroom Garbage Grinder Yes)No 1980orolder|150|2 total 110 220 Installed?(circle one) ‘Spa or Hot Tub Yes(No Installed?(circle one)1981-1991 130 1992-Present|110 PARCEL INFORMATION: ‘Topography 7 Fiat Rolling ‘Steep Slope %Slope Soil Nature __Sand Yi loam Clay ___Other (explain:JGroundwater‘At what depth?34” Bedrock/Impervious material|At what depth?greater than 54” Domestic Water Supply LAKE|__Municipal__Well (if well,water supply from any septic system absorption is___ft.) Percolation Test Rate:_12:00 per minute per inch (test to be completed by licensed engineer/architect) PROPOSED SYSTEM FOR NEW CONSTRUCTION: Tank size|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:16 x 30°Shallow Absorption Bed Holding Tank System Total required capacity?;tank size 7 #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:_dI779 WLMLE beEr pate:_&,iu [eco Bote DATE:LulzoSIGNATURE: ‘Septic Application Revised February 2019