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application '`A,�� Office Use Only SEPTIC DISPOSAL PERMIT APPLICATION Permit#: SC-P 20-20 Permit Fee:$ 1-3 ; Invoice#: 01; Septic Variance? Yes No Town of r eensbury 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.queensburv.net Tax Map ID#: Click or tap here to enter text. Project Location: Click or tap here to enter text. z93v caka q1 • Applicant: ectd-ezeI5I"" 7 �Y Name(s): Gregory Francis / Mailing Address, C/S/Z: 115 Technology Drive, B206,Trumbull, CT 066, Cell Phone: 203.913.7023 Land Line: ( ) D 0 Email: greg@korchek.com SEP 2 8 2020 ,, • Primary Owner(s): Name(s): above TOWN OF QUEENSBURY BUILDING&CODES Mailing Address, C/S/Z: Click or tap here to enter text. Cell Phone: ( ) Land Line: ( ) Email: Click or tap here to enter text. ❑ Check if all work will be performed by homeowner only • Contractor: Workers' Comp documentation must be submitted with this application Contact Name(s): Click or tap here to enter text. To . 8L b,Q-i"e✓'M Wed Contractor Trade: Click or tap here to enter text. Mailing Address, C/S/Z: Click or tap here to enter text.Cell Phone: ( ) Land Line: ( ) Email: Click or tap here to enter text. • Engineer(s): Name(s): Click or tap here to enter text. ege $,4-e 's r to r ,P -C Mailing Address, C/S/Z: Click or tap here to enter text. p, D. 8OX 6Z6S; S�rae. •/"Y 3211- Cell Phone: ( ) Land Line: ( ) '$9/ Email: Click or tap here to enter text. Contact Person for Building & Code Compliance: Click or tap here to enter text. Cell Phone: ( ) Land Line: ( ) Email: Click or tap here to enter text. Septic Application Revised February 2019 RESIDENCE INFORMATION: Year Built Gallons #of bedrooms: X gallons per =total daily flow per day bedroom 1980 or older 150 Click or tap here Click or tap Click or tap here to to enter text. here to enter enter text. text. 1981-1991 130 Click or tap here Click or tap Click or tap here to to enter text. here to enter enter text. Garbage Grinder l Yes No text. Installed? (check one) ❑ N 1992-Present 110 Click or tap , Click or tap Click or tap here to here to enter here to enter enter text. Spa or Hot Tub Yes No text. text. /Se9 111-0 Installed? (check one) ❑ N r v. t P'epelit..G.2Y1n/@ nd+ D " l.7.S4a 11 j J1/1 G/0.✓YiS Fyne A.? 4, o --�- PARCEL INFORMATION: ✓✓ y Topography ❑ Flat Rolling - © Steep Slope %Slope Soil Nature ❑ Sand ❑ Loam ❑ Clay ❑ Other(explain: Groundwater At what depth?Click or tap here to enter text. Bedrock/Impervious material At what depth?Click or tap here to enter text. 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: Tank size 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: 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:Gregory Francis 6/16_ SIGNATURE: Click or tap here to enter text. DATE: 9/22/2020 Septic Application Revised February 2019