application 9 A • 0
`" K :'. SEPTIC DISPOSAL PERM 4APP1�UCA-IL i Use se Onl
742 Bay Road,Queensbury, NY
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Tax Map ID#: ✓0/ . 7-- /—w;5� JUB 9 202 p 'r i F e: $ 7rW Invoice#:2 757
Project Location: 5- ( (�...,,� tic v� lance? Yes No
Primary Owner(s) A...eN ¢- ESMailing Address
5. 6UtCot_icia.JI_LDIpGr i
of cam.
Phone & Email I -- �/57�_5• �
Installer/Builder ))))
Mailing Address Lovv,,P� �� eh 5f ca,
Phone & Email l U- 1 J `4.` ��r'S v�'
U l� OI
Engineer
Mailing Address
Phone & Email
Contact Person for Building& Code Compliance: r_krt) Phone: c 1 )—2, ll
RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms X gallons per =total daily flow
per day bedroom Garbage Grinder Yes U:17/
1980 or older 150 Installed? (circle one)
1981-1991 130 Spa or Hot Tub Yes
1992-Present 110 j I Installed? (circle one)
30
PARCEL INFORMATION: _
Topography Flat Rolling Steep Slope %Slope
Soil Nature Sand Loam Clay Other
Groundwater At w at depth?
Bedrock/Impervious material At hat depth?
Domestic Water Supply _Municipal _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 cc9 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 CJ() ft.; Each Trench so ft.
Seepage Pit with #3 stone How many: ; Size:
Alternative System Bed or other type:
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 Ordinanc
PRINT NAME: I Q Lc\-e, DATE: 772o
c
SIGNATURE: DATE:7--2 20
Town of Queensbury Building&Code nforcemen
Revised March 2018