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..�F- - Office Use Only t Permit#: S 4 31 g 'Zo2O SEPTIC DISPOSAL PERMIT APPLICATION __e _ rrr it Fee:$ Invoice#: Town ofQucensbury D E D L 5 ti:Variance? Yes No 742 Bay Road,Queensbury,NY 12804 1.1 P:518-761-8256 www.queensbury.net JUL 15 2020 I , ° F QEEN Tax Map ID#: 3°6 , ) Is:;U', ,,�ING U& COSBDESURY Project Location: Lo 1 77 „mot,, IA,06 rf/ 2"ej-e, • Applicant: Name(s): ( 7�e .4, 4 / �.74 d- 5 . Mailing Address, C/S Z: L,30� Or X.. 6-0 �U..,e, S, a � -) Cell Phone:_(.c7E ) ' - Land Line: _(_) ; f j4--/a Email: cl 7)r)e.% ... dvi'Ti^,-e.! . G® • Primary Owner( `. Name(s): pItt- - f-A-c .5 Mailing Address, C/S/Z: / 7 7,./, ,.- A7. a e,^,g 17,J rr de/Z no 1 Cell Phone:_( ) Land Line: _( ) Email: ❑ Check if all wo k will be performed by homeowner only • Contractor: Work ' Comp ume�, tation must be submitted with this application Contact Name(s): ii !.,ieV,6/C. Contractor Trade: --/f G �/�l l , Mailing Address, C S/Z: 70 5� / tr. ,c2) ,;, ,, � , dam° .2 .� Cell Phone:_. ) 2- ®•7 Land Line: (/3 ) s—s/ -/D9- Email: c .e.A. r, e......) o►-. •c i d v,S' '-i"i •e,5 ,c...n i • Engineer(s): , /,--- Name(s): at-- ,e1 Mailing Address, C/S/Z: Z Q c z S • i .:., v c. /i! , j'.ZR&44' Cell Phone: ° ) 8)7 -00 % Land Line: _( ) Email: 7aP7 /*--"e11 9 Il'1 9c.,c'7 V15 t L35 N Contact Person for Building & Code Compliance: 4N ci�3'� C/C) Cell Phone: 'Z''Z - Lan Line: _( - ) �_ff - 7 p �Z Email: pie C © �-� : u � -{-r - ,G�lr-1.-• Septic Application Revised February 2019 RESIDENCE INFORMATION: Year Built Gallons #of bedrooms: X gallons per =total daily flow per day bedroom Garbage Grinder Yes E..) 1980 or older 150 Installed? (circle one) 1981-1991 130 Spa or Hot Tub YesC—No Installed? (circle one) 1992-Present 110 3 /1 0 776 PARCEL INFORMON: Topography 5ZFlat Rolling Steep Slope %Slope Soil Nature 31( N ci _Sand _Loam _Clay _Other(explain: Groundwater At what depth? Bedrock/Impervious material At what depth? Domestic Water Supply Munici al _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 SYST M FOR NEW CONSTRUCTION: Tank size A OOl allons(min.size 1,000 gallons, add 250 gallons for each garbage cylinder or spa/hot tub System Absorption field with#2 stone Total length /j q ft.; Each Trench 5j ft. ired Y Seepage Pit with#3 stone How many: ;Size: �.�..,ocf�� 5 Alternative System Bed or other type: 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 Di al Ordinance PRINT NAME: DATE:` /-14 6 SIGNATURE:. DATE: TiZ, Septic Application Revised February 2019