application , .!i,f. SEPTIC DISPOSAL PERMIT APPLICATION Office Use Only
'.',L,'T 742 Bay Road, Queensbury, NY 12804
P: 518-761-8256 _._ Permit#: EE- Oc-D ^ 29`2.,q
Tax Map ID#: 292 1- —1— Permit Fee: $ /1-5 ; Invoice#: WOO
Project Location: 7OLf PN-, d ,-e Rd, Septic variance? Yes No
,
Primary Owner Cs) Ur r
Mailing Address id ML
RIEVILSED
Phone & Email 5-1 37� 1
Installer/Builder J(3 5 5
�tJJ
Mailing Address
2 .Lo -Q r V re _1D11.' '.ji 4.4 te r ' ,-11
Phone & Email 5 S_ l lln\,A
Engineer 14 C, 4 11 J ` SEP 2 5 2020
Mailing Address I L
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�� �►G TOWN OF QUCENSBUIRY
Phone & Email
� 1 � 1�1_ 1 6 g BUILDING& CODES
Contact Person for Building & Code Compliance: Lie x(' IL_5 Phone: I V 1 — 1 1L)
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 Spa or Hot Tub Yes N
Installed? (circle one)
1992-Present 110 1 n `) n
PARCEL INFORMATION: tJ J
Topography F t Rolling Steep Slope %Slope
Soil Nature - Sand Loam Clay Other
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 ft.)
Percolation Test _ Rate: V ., per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size O4 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„ er— ft.
Seepage Pit with #3 stone How many: ;Size:
Alternative System Bed or other type: ;,a.' Yi C , , '" 4.1,y Yp , vi ^»t�,.. $=��'s����,li[���. 1�w:t,rN
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. _ ,.
t � p i/J
DATE:
PRINT NAME: L# /' 4t 'rl 1 I 9---)J-f--)--0
SIGNATURE: / DATE: 9-j)ifr/- n
Town of Queensbury Building& .de - en t Revised March 2018