application %_A: - ' SEPTIC DISPOSAL PERMIT APPLICATION
Office Use Only
742 Bay Road,Queensbury, NY 12804
P: 518-761-8256 Permit#:
W. (0.425- 202.E
Tax Map ID#: 3k • lb - k_y6 Permit Fee: $_Iti ; Invoice#: 2824z,
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Project Location: V� ___h
D Septic\/ rianre? Yew I No
Primary Owners) Ur r� CO LE }f E ff;
Mailing Address
Phone & Email 5 - _2, 9 — JUL 27 202i� HJ�
Installer/Builder ''— r - ..J
5____��_ 1 C TOWN OF QUEENSc3URY
Mailing Address �� l BUILD! &CODES
Phone & Email _ L 6e (t( cm')
Engineer -+
Mailing Address I 3 Li- 0 1 J-e. 't)C , I
Phone & Email SI � _ Q
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Contact Person for Building&Code Compliance: Ct;: Cjc Phone: J 1 77C�
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RESIDENCE INFORMATION:
Year Built Gallons # of bedrooms X gallons per = total daily flow
per day bedroom Garbage Grinder Yes N/
1980 or older 150 Installed? (circle one)
1981-1991 130 Spa or Hot Tub Yes No
Installed? (circle one)
1992-Present 110 3 \'J
PARCEL INFORMATION:
Topography at Rolling Steep Slope %Slope
Soil Nature Sand Loam Clay Other
Groundwater At w at depth?
Bedrock/Impervious material At hat depth?
Domestic Water Supply unicipal _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 F W CONSTRUCTION:
Tank size IDLA.)galflb�si(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: 1313_51-__—
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 Ordinan e. . 4
( if--)- 1 I `- �`�
PRINT NAME: DATE: ,—L U /
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SIGNATURE: ` --��
DATE:
Town of Queensbury Building&Code Enforcement Revised March 2018