application ,,;,. ' ' "V' SEPTIC DISPOSAL PERMIT APPLICATION Office Use Only
-ti 742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.clueensburv.net Permit#: se-P."0'3®2-2O2-
Tax Map ID#: 308.12-1-10 Permit Fee:$ -- ; Invoice#: 29 2--
Project Location: 22 WEST DRIVE Septic Variance? Yes No
Primary Owner(s) PETER ALCURI
Mailing Address 22 WEST DRIVE,QUEENSBURY,NY
Phone & Email �� Ig 0 V."E-_..0
Installer/Builder SANITARY SEWER SERVICES j
Mailing Address LUZERNE ROAD,QUEENSBURY NY AUGdl �� �
Phone & Email 5187963760 TOmri,i'96uaEueuNsu--1stusRY-
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Engineer TOM CENTER
Mailing Address 73 SHERIDAN STREET,GLENS FALLS,NY 12801
Phone & Email TCENTER36@YAHOO.COM
Contact Person for Building&Code Compliance: GEORGE DRELLOS phone: 5187963760
RESIDENCE INFORMATION:
Year Built #of bedrooms X gallons per bedroom =total daily flow Garbage Grinder Yes
1980 or older Installed? (circle one) '�
1981-1991 Spa or Hot Tub Yes No
Installed? (circle one)
1992-Present 2 110 220
PARCEL INFORMATION:
Topography ✓ Flat Rolling Steep Slope %Slope
Soil Nature Sand Loam Clay Other
Groundwater At what depth? DEEPER THAN 6'
Bedrock/Impervious material At what depth? NONE
Domestic Water Supply V Municipal _Well (if well,water supply from any septic system absorption is ft.)
Percolation Test Rate: 1'-5' per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size NEW1000 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 ____ ft.; Each Trench ft. _
Seepage Pit with#3 stone How many: :Size:
Alternative System Bed or other type: 20 X 25 FT BED
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: GEOR •• DR' LOS DATE: 8/20/2020
SIGNATURE: - c
Town of Queensbury Building&Code Enforcement Revised February 2017