septic application —, Office Use Only Permit#: � �o 457(0-7
0
(?�11 ) SEPTIC DISPOSAL PERMIT APPLICATION Permit Fee:$ r"f, o4 ; Invoice#:
Town orQuecnahury Septic Variance? Yes No
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net ��
lJ C E u `1�/ Efjil
Tax Map ID#: Z I . //— l—/ ll I AUG 01. 2019
Project Location: 1 Z (-au_ !2. i UWN OF OUEEi�SBURY
BUILDING&CODES
• Applicant:
Name(s): A 'ii.-r LFa+u,*jpv
Mailing Address, C/S/Z: /$ vet :577.,r-t "NZ 0_,FT0n4 parer- 1 zo63—
Cell Phone:isle )&f7-e 71 z— Land Line: _(
Email: /pML6 4i . QNYG ? OM.cc.n —I
• Primary Owner(s):
Name(s): 5A i hS A-+3�E
Mailing Address, C/S/Z:
Cell Phone:_( ) Land Line: _(
Email:
❑ Check if all work will be performed by homeowner only
• Contractor: Workers' Comp documentation must be submitted with this application
Contact Name(s): lAcj,,,q{zt-,0
Contractor Trade: 1Zc,s_wGc,e--, r3exg_p{y2_S
Mailing Address, C/S/Z: /? rnwy sc y i .r,f..c,Lf i2 L r -bi., ,(tt [ Zit 0
Cell Phone:_(SI )gr7-4371 . Land Line: (
Email:
• Engineerrst:
Name(s): Arx,"//kce i4C._ a- CL RveY/N6— / pi,G.
Mailing Address, C/S/Z: it h'e z,,52..—,— [>e_ "t rf re.Il O
Cell Phone:_( ) Land Line: (p )678 - 7 7'7 7--
Email: /•IGc.,S i�J-p€ e G 4-4 .GcJI•�
Contact Person for Building & Code Compliance: An,,,t /&„,4,44 4C)
Cell Phone: (g76 ) Land Line: ( )
Email: A:.o.41.1/mac)e".4-2T>CD @"I ye A-('. Xi?. G.vh-(
Septic Application Revised February 2019
RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms: X gallons per =total daily flow
per day bedroom Garbage Grinder Yes V
1980 or older 150 Installed? (circle one)
1981-1991 130 Spa or Hot Tub Yes o
Installed? (circle one)
1992-Present 110 f/® 111740
PARCEL INFORMATION:
Topography Flat Rolling Steep Slope /3 %Slope
Soil Nature K-Sand _Loam Clay kOther(explain: etzveZ5
Groundwater At what depth? ,,— ehcor,J,N c
Bedrock/Impervious material At what depth? 6 4cex,rf r En
Domestic Water Supply _Municipal _Well (if well,water supply from any septic system absorption is ft.)
Percolation Test Rate: 3 per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size /000 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: / pe Ate o Fi p•S
Holding Tank System Total required capacity? ;tank size ;#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. 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: / 4Ivj DATE: Va.
/5
SIGNATURE: DATE: V2(r/0,
Septic Application Revised February 2019