application it / Office Use Only
SEPTIC DISPOSAL PERMIT APPLICATION Permit#: 'e0 33-1,zoZg
,, Permit Fee: $ `75TC) ; Invoice#: 14 3 Z
Town orcZ sb��ry Septic Variance? IV Yes No
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net
ECE11 WED '
Tax Map ID#: c27 - 1 -31
JUN 01 2019
Project Location: , "/ 864 E, A* N
TOWN OF QUEENSBURY
BUILDING&CODES
..........
• Applicant:
Name(s): H/0-:. c4A-1-gr�—
Mailing Address, C/S/Z: ag sm.- Rt. (Yqi
Cell Phone:_( ) Land Line: _(,1'7c ) 7 g_V/ -15'
Email:
• Primary Owner(s):
Name(s): /''lifi, - b -)--
Mailing Address, C/S/Z: 5i 1 sty}-ice Rt. / 9
Cell Phone:_( ) Land Line: _Wee:, ) 79 2t.5
Email:
❑ Check if all work will be performed by homeowner only
• Contractor: Workers' Comp documentation must be submitted with this application
Contact Name(s): I S5 S. 'I'lC, ,AMID D .% t
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: _( )
Email:
• Engineer(s):
Name(s): tLCA 1 . l,( 1'T ?�1�Q.
Mailing Address, C/S/Z: (Wk. plc lk 1 CF( IS Ufa 14\4 12&a1
Cell Phone: _( ) _ Land Line: _( SIg ) 1 4-Caro&
Email: ,gyphallt Y1 yet p-CC. laelacitr GOvr
Contact Person for Building & Code Compliance: j1.41.1 PAL.
Cell Phone: ( ) Land Line: ( so )144-O24'
Email: ei0h01 l( a V►WCaio ,rr: wren
Cumin A....li..-.ki.... 1,...._...J L..L.-....-..'MI n
RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms: X gallons per =total daily flow
per day bedroom Garbage Grinder Yes 410
1980 or older 150 Installed? (circle one)
1981-1991 130 Spa or Hot Tub Yes o)
Installed? (circle one)
1992-Present 110 ( 11 o
PARCEL INFORMATION:
Topography "Flat Rolling Steep Slope 5 %Slope
Soil Nature _Sand ✓Loam"MA. Clay Other(explain: •i(f L,�, )
Groundwater At what depth?
Bedrock/Impervious material At what depth?
Domestic Water Supply _Municipal Well (if well,water supply from any septic system absorption is 60 ft.)
Percolation Test Rate: 'D per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size 42,60gallons (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: (..t (10i�D� Sem •
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 Disposal Ordinance.
PRINT NAME: i`'1)kr (,J,5-48zap DATE: ?/- 36.. fi
SIGNATURE: �IX., DATE: 9- 30-1c(
Septic Aoolication Revised February 2019