application r I
26
}' :, r SEPTIC DISPOSAL PERMIT APPLICATION Office Use Only
742 Bay Road, y,
r.•, .,, ' •; Queensbury, NY 12804 pewit P: 518-761-8256 ,,:, .r"` I� IM c E Ue V t 'U:S�Ii- ZUzU
Tax Map ID#: 3 U Li— i---Z�S ° i( ` Permit Fee 7�10; Invoice#: 2.-WO
Project Location: -7 nO4) SEP 18eara ? Yes No
Primary Owner s ,wt\ OF QUEENSBURY
Mailing Address � C—ODE'
Phone & Email 5 i- .;,,3'.
Installer/Builder �
r
Mailing Address
Phone & Email i
L-- 17— $( (�
Engineer J D
Mailing Address
Phone & Email
•
Contact Person for Building &Code Compliance: Cl.(`I) Phone: 'I !-3 t1 2*6�
RESIDENCE INFORMATION: 410'L7\'Z.p
Year Built Gallons # of bedrooms X gallons per = total daily flow _, L') C, 't
per day bedroom • Garbage Grinder i No r
1980 or older 150 Installed? ( ircle one) I
1981-1991 130 - • Spa or Hot Tub No
Installed? (circle one)
1992-Present 110 33 (\
PARCEL INFORMATION: . �)
Topography lat Rolling Steep Slope %Slope
Soil Nature Sand _Loam Clay Other
Groundwater At hat 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 FOF N W C9NSTRUCTION:
Tank size I(W)CVI/Tri)�m n. size 1,000 gallons, add 250 gallons for each garbage cy .n er or spa/hot tub
System Absorption field with #2 stone Total length TO 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. _<
PRINT NAME: ^0,.
It Ai " �_ / DATE: 9-1 r--f/
SIGNATURE: ► r
aJPr'A PP: , I DATE: q-ft--A
Town of Queensbury Building&Code Enforcem:n', , Revised March 2018