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4/ / Office Use Only ' \ 1 Permit#: 363— GWV" 2©Z° SEPTIC DISPOSAL PERMIT APPLICATION Permit Fee: $ ; Invoice#: 2-154n limn a ,c Septic Variance? Yes No 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.queensbury.net Tax Map ID#: N 2 ' Y4 - 1- -\- Project Location: ad L L1 p,H i l-c,r,-t. • Applicant: ��. Name(s): CJDle- .L_DS /G`)&7'or7s Mailing Address, C/S/Z: V"'OS i. 27 ja/1 .4;;; ‘,. , di! /28/ Cell Phone: _(58 ) Z7Z- Z70 Land Line: _(5 9 ) 58 /v*'$ Email: d+.a.►-,e 6+2 rve., or)off L. S+ -'i�S oGc*,-, • Primary Owner(s): Name(s): I?I y.h 62/3 S - B y-'-r YI( fl4cd�iy- c-' Mailing Address, C/S/Z: /,A L .,j7,., jam.. , 0,1«t-.5 L 1' 7 . AJ.V' ) 2.430 Cell Phone: _(ciB ) Z.e>3-- SV-3/ Land Line: _( ) Email: a .,.� j ,c l ,(o- , ❑ Check if all work will be performed by homeowner only • Contractor: W kers' Com documentation must be submitted with this application Contact Name(s): �4...4., l �-e3. �,1z. Contractor Trader 5r7�s�'� 5 Mailing Address, C/S/Z: °�Foc- /`��"e. cz Our�1-0��e,., AI P / Z Gg Cell Phone: _(51E, ) 272-X707 Land Line: _( 5if3 ) SBA.- o a Yig Email: el cc. ‘,4 .v ,fr,A ems+,—a . - c --, • Engineer(s): Name(s): • c r TV NI Mailing Address, C/S/Z: gm ... Cell Phone: _( ) Land Line: _( ) Email: AUG 06 2020 TOWN OF OUE NBDUR.Y BUD DING&CODE'S I Contact Person for Building & Code Compliance: -,c.., .,.pdL�4..... Cell Phone: ( ) z,'Z- g707, Land i ne: _( 670 ) ,c3 V- " / Email: tec..., 'c,.ie, t .- A a .-E-1-9-cs , Septic Application Revised February 2019 • , RESIDENCE INFORMATION: Year Built Gallons #of bedrooms: X gallons per =total daily flow per day bedroom Garbage Grinder Yes No' 1980 or older 150 Installed? (circle one) 1981-1991 130 g Spa or Hot Tub Yes � ��f d Installed? (circle one) COP 1992-Present 110 PARCEL INFORMATION: Topography )(--Flat Rolling Steep Slope %Slope Soil Nature Sand _Loam _Clay _Other(explain: Groundwater • At what depth? Alewe 71-6 7 Z'< Bedrock/Impervious material At what depth? /VD7e Domestic Water Supply ,Municipal _Well (if well,water supplyfrom 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 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 HO ft.; Each Trench cic ft. i/ ..29 Seepage Pit with#3 stone How many: ;Size: Act. Alternative System Bed or other type: 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 Dis osal Ordinance. J PRINT NAME: Ga_ l_✓`U +G DATE: 7'5I� ZOZO SIGNATURE: DATE: 7`,p- Zd ZD Septic Application Revised February 2019