application i
SEPTIC DISPOSAL APP SIM, a wifE Office Use Only .
Received
DATE: 2020 Tax Map ID
JUL 21 Permit No. n
TAX MAP ID: Permit Fee `- .tihva►Zv 2.b0b
ZONE: TOWN OF QUEENSBURY
BUILDING&CODE!
APPLICANT S--\-r,_k 1 p-1 ki 5 S2 c Scv t c2� PHONE/E-MAIL
ADDRESS ri z S i s so t' 2c1 S i.,,,,..or, (,t, ,s t\5 lit`i t aB o
INSTALLER/ PHONE/E-MAIL
BUILDER S4-- CI t- - S p4; L S•e r v'i Le__
OWNER f}'=i ck. H 2r gye-k
ADDRESS fl i-1-, it cre s.+ Q-1 Je_ (:),,,,2_r)sb u,-Li ki Y f aV '71
CONTACT PERSON FOR BUILDING&CODE COMPLIANCE:S•G_k S1-re... Cl I
PHONE/E-MAIL S1? 9 44-g`2J1 3
RESIDENCE INFORMATION
Year Built #of bedrooms X gallons per bedroom =total Daily flow meet,,EV ' b..1.- `C --V 7'c___
1980 or older Garbage grinder installed Yes 144o
1981-1991 Spa or Hot Tub installed ' Yes /No
1992-Present 3 1 1 o 3 3 .5- e_A FCC® QA hi"Q-ANA t-,tsA bE?rtC._.
PARCEL INFORMATION `
Topography c/ Flat rolling Steep slope %Slope
Soil Nature /Sand Loam Clay Other
Groundwater At what depth:
Bedrock/Impervious material At what depth:
Domestic Water Supply J 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 1 t oo gallons(min.size 1,000 gallons,add 250 gallons to size for each garbage cylinder or spa or hot tub
System Absorption field with#2 stone Total length/S"(. ft.;Each Trench_5'U
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&approved. The installed system must match the
septic system 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 allrequirements of the Town of Queensbury Sanitary Sewage Disposal Ordinance.
PRINT NAME: SACz&4J/7 ,9i^�'� , . DATE: 7_,a/'-ac%)-c
SIGNATURE: a.), 1��.5 DATE: '7`A/—a0o2 a
Town of Queensbury Building&Codes . Principal Structure Application Revised September 2014