application :+
SEPTIC DISPOSAL PERMIT APPLICATION Office Use Only
742 Bay Road, Queensbury, NY 12804
P: 518-761-8256 - Permit
Tax Map ID#: CO
t-51 Permit Fee: $ ; Invoice#:Project Location: 4*1 `Onr\ C `�S C 64,,� �"(� ` Septic variance? Yes � No
Primary Owner(s) 65 pl, Jro\ ""�n i ( kl��
Mailing Address �-� f �� _ �!_ F-,
Phone & Email`
Installer/Builder - _C>A zU2 it it
Mailing Address
Phone & Email _ T- J
Engineer
Mailing Address T
Phone & Email
Contact Person for Building & Code Compliance: ` Phone: I—� 0
RESIDENCE INFORMATION:
Year Built Gallons # of bedrooms X gallons per = total daily flow _
_ per day _ - bedroom Garbage Grinder Yes No/�
1980 or older. ISO Installed? ('circle one)
1981-1991 130
-- Spa or Hot Tub Yes o
110 Installed? (circle one)
1992-Present 110 r��o '---`
PARCEL INFORMATION: ~--
Topography _ /at Rolling Steep Slope %Slope
Soil Nature Sand Loam Clay Other _
Groundwater _ At w t depth? -
Bedrock/Impervious material At Khat depth?
rDomestic 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 WA gallons (min. size 1,000 gallons, add 250 gallons for each garbage cylinder or spa/hot tub _
System Absorption field with 42 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 & 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.
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: r DATE:
L �2�
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SIGNATURE: DATE:
Town of Queensbury Building&Code Enforce en Revised March 2018