Loading...
application Office Use Only, '44 34. Permit#: -V*0t— SEPTIC DISPOSAL PERMIT APPLICATION Permit Fee: $ fy50 , Invoice#: '3l3'S cs -- Town ofQuee sbury Septic Variance? Yes V No 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.queensbury.net Tax Map ID#: 289.9-1-87 jur © i OW ( 7- Project Location: 298 Glen Lake Road I,I NOV 10 2020 u jj TOWN OF QUEENSBURY • Applicant: BUILDING&CO DES Name(s): Christine Mozal Mailing Address, C/S/Z: P.O. Box 4266 Queensbury, NY 12804 Cell Phone: ( 518 ) 796-5753 Land Line: _( Email: • Primary Owner(s): Name(s): same as applicant Mailing Address, C/S/Z: Cell Phone: _( ) 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): IBS Septic- Chris Bell Contractor Trade: Septic Installation Mailing Address, C/S/Z: 2 Lower Warren Street Queensbury NY 12804 Cell Phone: ( 518 ) 361-2465 Land Line: _( ) Email: • Engineer(s): Name(s): Hutchins Engineering PLLC Mailing Address, C/S/Z: 169 Haviland Road Queensbury, NY 12804 Cell Phone: _( ) Land Line: (518 ) 745-0307 Email: thutchins@hutchinsengineering.com Contact Person for Building & Code Compliance: Torn Hutchins& Chris Bell Cell Phone: ( 518 ) 361-2465 (Chris Bell) Land Line: ( 518 ) 745-0307 (Tom Hutchins) Email: thutchins@hutchinsengineering.com Septic Application Revised February 2019 • 2-story wood framed restaurant- 1,500 Gallon per day per prior design Year Built Gallons #of bedrooms: X gallons per =total daily flow per day bedroom Garbage Grinder Yes No 1980 or older 150 --- --- 1,500 GPD Installed? (circle one) 1981-1991 130 Spa or Hot Tub Yes No Installed? (circle one) 1992-Present 110 PARCEL INFORMATION: Topography ✓ Flat Rolling Steep Slope %Slope Soil Nature ✓ Sand _Loam _Clay _Other(explain: 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: per minute per inch (test to be completed by licensed engineer/architect) PROPOSED SYSTEM FOR NEW CONSTRUCTION: (2) 2,000 gallon existing septic tanks Tank size 4,000 gallons (min.size 1,000gallons, 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: 4 beds each 10'x 56' 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. A6c-iv PRINT NAME: GDATE: SIGNATURE: DATE: 1/t, 9/ Septic Application Revised February 2019