application dA
-- SEPTIC DISPOSAL PERMIT APPLICATION Office Use Only
742 Bay Road,Queensbury,NY 12804
Town of Otieensbury P:518-761-8256 www.queensbury.net Permit#: { '��4� " ��
Tax Map ID#: 290.5-1-67 Permit Fee:$ 3-6 ; Invoice#: Z'a-O'ab
Project Location: 12 BROOKWOOD DRIVE Septic Variance? Yes No
Primary Owner(s) SUSAN BORLANG
Mailing Address 12 BROOKWOOD DRIVE QUEENSBURY,NY 12804
Phone & Email 66I _- _ - w
Installer/Builder SANITARY SEWER SERVICES 1 fll e I \'N1 ! ' I
Mailing Address LUZERNE RD, QUEENSBURY NY j l) M6 2U1U I II I
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Phone & Email 518-796-3760 I n
Engineer HUTCHINS ENGINEERING TOWN OF QUEENS UURY
Mailing Address 169 HAVILAND ROAD, QUEENSBURY NY 12804 I BUILDING 8.CODES 1
Phone & Email 518-796-2515 TCENTER36@YAHOO.COM
Contact Person for Building&Code Compliance: GEORGE DRELLOS Phone: 518-796-3760
RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms Xgallons per =total daily flow
per day bedroom Garbage Grinder Yes No
1980 or older 150 Installed? (circle one)
1981-1991 130 Spa or Hot Tub Yes No
Installed? (circle one)
1992-Present 110 4 110 440
PARCEL INFORMATION:
Topography ✓ Flat Rolling Steep Slope %Slope
Soil Nature ✓ Sand Loam Clay Other
Groundwater At what depth? 40"
Bedrock/Impervious material- At what depth? GREATER THAN 50"
Domestic Water Supply( ;r._Municipal ✓ Well (if well, water supply from any septic system absorption is 102 ft.)
Percolation Test Rate: 1 per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size 1,250 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: 15x40 pipe-in-stone absorption bed
Holding Tank System Total required capacity? ;tank size ;#of tanks
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 and approved.
The installed system must match the septic layout 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 known by or on behalf of an applicant, shall be void. I
have read the regulations and agree to abide by these and all requirements of the Town of Queensbury Sanitary Sewage
Disposal Ordinance.
PRINT NAME: 7 4,041 bzy c t„-- DATE: r/24,1..d
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SIGNATUR � ..
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Town of Queensbury Building&Code Enforcement Revised March 2018