application 3, SEPTIC DISPOSAL PERMIT APPLICATION Office Use Only
742 Bay Road,Queensbury,NY 12804
Town ot'Q ecnsbury r' O�� �' �'T
P:518-761-8256 www.queensbury.net Permit#: /3J
Tax Map ID#: 302.17-1-4 Permit Fee: $ ; Invoice#:22"2-\
Project Location: 19 ARBUTUS DRIVE Septic Variance? Yes No
Primary Owner(s) JOEL BOBICK
Mailing Address 19 ARBUTUSDRIVE,QUEENSBURY,NY
Phone & Email 1—_.7a_._---m
Installer/Builder SANITARY SEWER SERVICES 1 Ii) ii" lit jl !9 LE in')
Mailing Address LUZERNE ROAD,QUEENSBURY NY / T) T '
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Phone & Email 5187963760 ! L JUL 6 i 2023 I IL) 1
Engineer TOM CENTER TOWN )
OF�?i,l� €�i--�i�:s A.-7,�.
Mailing Address 73 SHERIDAN STREET,GLENS FALLS,NY 12801 BC�IL DIN a& CODES
Phone & Email TCENTER36@YAHOO.COM
Contact Person for Building&Code Compliance: GEORGE DRELLOS Phone: 5187963760
RESIDENCE INFORMATION:
Year Built #of bedrooms X gallons per bedroom =total daily flow Garbage Grinder Yes No
1980 or older Installed? (circle one)
1981-1991 Spa or Hot Tub Yes s(E)
Installed? (circle one)
1992-Present 4 110 440
PARCEL INFORMATION:
Topography ✓ Flat Rolling Steep Slope %Slope
Soil Nature Sand Loam Clay Other _
Groundwater At what depth? DEEPER THAN 6'
Bedrock/Impervious material At what depth? NONE
Domestic Water Supply ✓ Municipal _Well (if well,water supply from any septic system absorption is ft.)
Percolation Test Rate: 1'-5' per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size EXISTING 1250 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: 20 X 30 FT 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: GEO E DRELLOS DATE: 6/30/2020
SIGNATURE: i �/f JL
,_XVX
Town of Queensbury Building&Code Enforcement Revised February 2017