application f::,:g.,': ;
SEPTIC DISPOSAL PERMIT APPLICATION Office Use Only
742 Bay Road, Queensbury, NY 12804
P: 518-761-8256 Permit#: P�F�Di - 2.,Z.O
Tax Map ID#: 561 c� "`�. 1 l 1, Permit Fee: $ t . ; Invoice#:282.1'
Project Location: 6 gi 5ke r r,A, (-\Q . Septic Variance? Yes )` No
Primary Owner(s) r L
Mailing Address 9 C l'n • — —
Phone & Email I _5Jm _ 91 CH.
Installer/Builder 5 S-eP.{_i
Mailing Address "� LO ln� r _ 5-i-. 0 keen5 r
Phone & Email Y--1 Q�_ W ��. C`\ ►�Cn
Engineer / 11 it-"Th
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n w
Mailing Address I -
Phone & Email _ JUI 27 2020
674
Contact Person for Building & Code Compliance: _i ``.2
TQWN 01- O N;�MURY J�C n
RESIDENCE INFORMATION: BUILDING&CODES
-Q7 /
Year Built Gallons # of bedrooms X gallons per = total daily flow
per day bedroom Garbage Grinder Yes No
i/
1980 or older 150 Installed? (circle one)
1981-1991 130 Spa or Hot Tub Yes N
3 W__ 3IL) Installed? (circle one)
1992-Present 110 ,
J`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 _ 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)
PROPO� YSTEM FOR NEW CONSTRUCTION:
Tank sizer',r�`�103(1 gallons (min. size 1,000 gallons, add 250 allons for each garbage cylinder or spa/hot tub
System Absorption field with #2 stone Total length 2- ft.; Each Trench 5 0 ft. f,� c_.o c
Seepage Pit with #3 stone How many: ; Size: r-- c� \)e_ S2
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 Ordinance.
PRINT NAME: CLr O +op e. s� (.)--e DATE:
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SIGNATURE: DATE: ?-1L1-- )0
Town of Queensbury Building&Code Enforcem Revised March 2018