application Office Use Only
Permit#: sey - 0"+�• U?�J
SEPTIC DISPOSAL PERMIT APPLICATION Permit Fee:$ Invoice#: 3ZV3
Town ofQuecnsbury Septic Variance? Yes ✓ No
742 Bay Road,Queensbury,NY 12804
P:518461-8256 www.aueensburv.net
Tax Map ID#; 302.14-1-2
Project Location: 9 HUGHES COURT -�._
• Applicant:
Name(s): TIM PLACE SEC O 2020 i J E`
Mailing-Address, C/S/Z: 9 HUGES COURT,QUEENSBURY, N Y 12804
Cell Phone: _( ) Land Line: ��
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Email: ,.
• Primary Owner(s):
Name(s): SAME
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: _( )
Email:
0 Check if all work will be performed by homeowner only
• Contractor: Workers' Comp documentation must be submitted with this application
Contact Name(s): GEORGE DRELLOS
Contractor Trade: SANITARY SEWER SERVICES
Mailing Address, C/S/Z: LUZERNE RD, QUEENSBURY, NY 12804
Cell Phone: _( 518 ) 796-3760 Land Line: _( )
Email:
• Engineer(s):
Name(s): CENTER PROJECT SERVICES, TOM CENTER .
Mailing Address, C/S/Z: 73 SHERIDAN STREET, GLENS FALLS,NY 12801
Cell Phone: _(518 ) 796-2515 Land Line: _( )
Email: TCENTER36@YAHOO.COM
Contact Person for Building & Code Compliance: GEORGE DRELLOS
.Cell Phone:_( 518 ) 796-3760 Land Line: _( )
Email:
Septic Application Revised February 2019
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 j 3 110 330
PARCEL INFORMATION:
Topography ✓ Flat Rolling Steep Slope %Slope
Soil Nature ✓ Sand _Loam _Clay _Other(explain: )
Groundwater At what depth? 52- 60"
Bedrock/Impervious material At what depth? NA
Domestic Water Supply ✓_Municipal _Well (if well,water supply from any septic system absorption is ft.)
Percolation Test Rate: 1-5 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: 20 X 25
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: - /�` DATE: /�'1® 20
SIGNATURE: DATE; --A9
Septic Application Revised February 2019