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SEPTIC DISPOSAL PERMIT APPLICATION :$ ; Invoice#:
Septic Variance? Yes No
Town of Queensbury
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net
Tax Map ID#: 288.-1-82
Project Location: 111 Old West Mountain Road ( 1,0EZ,Z1)c u c J W ` 1Z8o�
• Applicant: REVISED
Name(s): David Parker
Mailing Address, C/S/Z: 111 Old West Mountain Road, Queensbury, NY 12804
Cell Phone: _(51(R ) (a —chi 1 1 Line: _( t; l C�� .9 --` 539_
Email: o, il " . SA._ 0, • i v �n -_
• Primary Owner(s): NOV 0-912020r-
Land
Name(s): Same aVVld c�`"®�T I
Mailing Address, C/S/Z: t31►► , i QUEEN S
Cell Phone: _( � ) u� ES_( ) Land Line:
Email:
❑ Check if all work will be performed by homeowner only
• Contractor: Workers' Comp documentation must be submitted with this application
Contact Name(s): Ellsworth &Son Excavating
Contractor Trade: Site work
Mailing Address, C/S/Z: 10302 State Rt. 149, Fort Ann, NY 12827
Cell Phone:_( 518 ) 361-1993 Land Line: _(518 ) 792-9246
Email: digging@ellsworthexcavating.com
• Engineer(s):
Name(s): Hutchins Engineering
Mailing Address, C/S/Z: 169 Haviland Road, Queensbury, NY 12804
Cell Phone: _( ) Land Line: _(518 ) 745-0307
Email: LWDobie@hutchinsengineering.com
Contact Person for Building & Code Compliance: Ruben Ellsworth
Cell Phone: ( 518 ) 361-1993 Land Line: ( 518 ) 792-9246
Email:
Septic Application Revised February 2019
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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) X
1981-1991 130 Spa or Hot Tub Yes No
Installed? (circle one) X
1992-Present 110 4 110 440
PARCEL INFORMATION:
Topography ✓ Flat Rolling Step Slope %Slope
Soil Nature ✓ Sand _Loam _Clay Other(explain: 6,69 , )
Groundwater At what depth? > 50"
Bedrock/Impervious material At what depth? > 50"
Domestic Water Supply _Municipal _Well (if well, water supply from any septic system absorption is ft.)
Percolation Test Rate: 9:30 per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size 1000 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: 15'x 45' Bed
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: 1.04., „j/ i / t 4 •./26/,.// DATE: / //4/
SIGNATURE: prar
' DATE: / 1/4�Zd
Septic Application Revised February 2019