application gig
y : ,V SEPTIC DISPOSAL PERMIT APPLICATION Office Use Only
7''i'n'''" 742 Bay Road, Queensbury, NY 12804
P: 518-761-8256 ;...- • -J•:.-::-.2.2- ::.; Permit#:
Tax Map ID#: Z L — Permit Fee: $ ; Invoice#:act �Q.(�
Project Location: If T w i C \Ai Q Q (1 Lr\o _ Septic Variance? Yes No
Primary Owner(s) 5-�p"'en fil0 ePs
Mailing Address 11 '�W,� C. liv can31_E d `
Phone & Email r� r =— ,,
Installer/Builder U 4 1 i t
Mailing Address
Phone & Email 51, _1 q.y„ (l c _ I — I
Engineer BUILDING&CODES
Mailing Address -
Phone & Email
Contact Person for Building &Code Compliance: Clv,t3 VI Phone: S L 0 '3 -CI
RESIDENCE INFORMATION:
Year Built Gallons # of bedrooms X gallons per =total daily flow elf\ r ovd
per day bedroom Garbage Grinder No
1980 or older 150 • Installed? (circle one)
1981-1991 130 Spa or Hot Tub Yes No /
1992-Present 110 1 i 0 ! �^
Installed? (circle one) v
PARCEL INFORMATION: 1 �1
Topography • lat 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)
PROPOSED SYSTEM FOR NEW CONSTRUCTION: .
Tank size 175.() gallons (min. size 1,000 gallons, a ld 250 gallons for each garbage cylinder or spa/hot tub
System Absorption field with #2 stone Total length'Z5( ft.; Each Trench. . ( ft.
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 Ordinance. .yz;
PRINT NAME: k .,)+ -(- , t° DATE: ✓ ✓1 C _��
al WIM‘
SIGNATURE: /' 13a,l' -I
DATE: ()%1 —)--(*)
Town of Queensbury Building&Code Enforcement I Revised March 2018