application SEPTIC DISPOSAL PERMIT APPLICATION Office Use Only
742 Bay Road,Queensbury, NY 12804
Town of Queensbury P:518-761-8256 www.queensbury.net Permit#:cJG► (a
Tax Map ID#: 301.15-1-36 Permit Fee: $ ; Invoice#: 36 1-L
Project Location: 13 BRIGGS COURT Septic Variance? Yes No
Primary Owner(s) KEMM WILSON
Mailing Address 13 BRIGGS COURT,QUEENSBURY,NY
Phone & Email
Installer/Builder SMITHS EXCAVATING _.. ll�' C 1.1 If1\
Mailing Address 23 VERMONT AVENUE,QUEENSBURY NY L -- ' 11 11
Phone & Email 5187981836 OCT 19 2020 i I fir'
Engineer TOM CENTER
Mailing Address 73 SHERIDAN STREET,GLENS FALLS,NY 12801 iJ•?_ "°'•`y '' 'LL;''_
Phone & Email TCENTER36@YAHOO.COM �` -
Contact Person for Building&Code Compliance: FRED SMITH Phone: 518-798-1836
RESIDENCE INFORMATION:
Year Built #of bedrooms X gallons per bedroom =total daily flow Garbage Grinder Yes No
1980 or older Installed? (circle one)
1981-1991 Spa or Hot Tub Yes No
Installed? (circle one)
1992-Present 4 110 440
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 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 Ex.1250 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 35 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: FRED SMITH DATE: 8/20/2020
SIGNATURE: -a ff 2-
Town of Queensbury Building&Code Enforcement Revised February 2017