application :-.:.,- -'1;:- SEPTIC DISPOSAL PERMIT APPLICATION Offiec-1Jse-0.niv
r ". 742 Bay Road,Queensbury, NY 12804
tTD iL . ... O-2,9'q— �P: 518-761 8256 nr.r r: its "• . I I
Tax Map ID#: 27Sr, /C—(- - l� JUL ZI{�r f eE: . CYJ ; Invoice#:
Project Location:
)7 ti 00 �`1 a ��S""c���ttriahce? Yes No
OWN OF EzE f��'
Primary Owner(s) BUILDING&CODES
Mailing Address o
Phone & Email � �� -, �� � ��
51 � O—If451
Installer/Builder I t S pT `
Mailing Address 2 Low Wrayre , Si- Qj u`e f^ 5 b(n cy H1
Phone & Email 5 l -1 O1 [1—X
Engineer DUU l
Mailing Address -
Phone & Email
Contact Person for Building& Code Compliance: C k r,) f)..e �•I Phone: c 1 U 361 2 ` ‘c
RESIDENCE INFORMATION:
Year Built Gallons # of bedrooms X gallons per =total daily flow V ff. I fi t
/d
per day bedroom Garbage Grinder Yes No
1980 or older 150 Installed? (circle one) ✓✓
1981-1991 130 Spa or Hot Tub Yes No,/
1992-Present 110 ��� Installed? (circle one) ''✓✓
PARCEL INFORMATION: I
Topography lat Rolling Steep Slope %Slope
Soil Nature and Loam Clay Other
Groundwater At what depth?
Bedrock/Impervious material At what depth?
Domestic Water Supply —Municipal Well (if well, water supply from any septic system absorption is IOOft.)
Percolation Test Rate: per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size IO(10 gallons (min. size 1,000 gallons, add 250 gallons for each garbage c lliinnd�er roc spa/hot tub System Absorption field with#2 stone Total length -(Eri'; j1ft.; Each Trench tlJ_ft. ef4t j d
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
t PRINT NAME: hDATEri J it (� �- f'..-7
:
S -10
SIGNATURE: % ) DATE: n� iJn
Town of Queensbury Building&Code Enfor"ment Revised March 2018