historical info TOWN OF QUEENSBURY
BUILDING & CODE ENFORCEMENT
742 Bay Road
Queensbury NY 12804
(518)761-8256
SEPTIC DISPOSAL SYSTEM INSPECTION
Name 6.e=r.k(f9
Location
Date AOKh Permit #
SOIL TYP ; Sand-Loam-Clay-
Results of\Percol ati on Test.
(if applicable) Rate-Minute/Inc ,.
TYPE OF\SYSTEM:
ABSORPT ! FIELD: Total Length
Length o each\trench
Depth of trenches
Size of sone '1
SEEPAGE PITS: Number-
Size - ft. x ft.
Stone size [
PIPING: Size Type
Bldg. to Tat; 1 1- -) O
Tank to Dist. Box1
Dist. Box to ,Fi elf d/Pik,,
Openings Seale!? es No Partial
LOCATI 1/SEPA TJON .
Foundation tonk S2 feet
Foundation to Absorption feet
Separation of P{i tts feet
Conforms as pet' Plot Plan Yes No
LOC TION OF SYSTE‘ON PROPERTY:
' -c0 one)
Front Rear - Left Side m Right Side
1 die Front - Middle Rear
COMMENTS: \
57, 6./ft-z-,. k IA). , k,,,k u fv\ Ogt-I>N6
7 c6 6/ c' — pK
SYSTEM USE APPRrVED: ES NO
Arrived: • i
Departed: pl___
Ve--'
Building Inspector
Application for SEPTIC DISPOSAL PERMIT
Town of Queensbury Permit No.
Dept. of Community. Development /
Building &Codes Office F 1 V E 1
742 Bay Road E b Fee Paid $
Queensbury, NY 12804 OCT 1 2
Location of property for installation: __ r,.r� . ` �0-ir
Property Owner's Name: IS R-J-'r /M'2 i A o e'A/IC--
Property Owner's Mailing Address: l,.4)"a.V e (/AV k ki6 J /1 t�-tft
Installer's Name: Gi+g s D 1/ Phone # 19 3-0 113/
Number of bedrooms (if residential): ' Total daily flow: o
sidential - compute @ 150 gal./bdrm.)
Topography: flat, rolling, ) , steep slope ! f slope
Soil Nature: sand, loam, clay, ' other/depth:
Ground water: at what depth? feet / Bedrock or Impervious Material: at what depth? feet
Percolation test: not required, required [ra min. per inch]
Domestic water supply: municipal, I well, other
If domestic water supply is a WELL, water supply from any septic absorption is 11 feet. .
PROPOSED SYSTEM
Septic tank: gallon (minimum size: 1,000 gal.)
Tile field: each trench feet / Total system length: feet
Seepage pit(s): number of / size each: ft. by ft.
Size of stone to be used: #. / depth or thickness feet
•
HOLDING TANK SYSTEM: (if required) �.�-
Number of tanks: 3 Size of each: ) r��1 o gallons
CAmarmsystemn and associated electrical work to be inspected by a certified agency.
For your protection, please note that pursuant to Section 136-29 of the Code of the Town of Queensbury, any permit or
approval granted which is based upon or is granted in reliance upon any material misrepresentation 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 with respect to this application and agree to abide by these and all requirements of the Town of
Queensbury Sanitary Sewage Disposal
Signature of responsible person: (7" � Date: i 91