application Nam, SEPTIC DISPOSAL PERMIT APPLICATION Office Use Only
742 Bay Road, Queensbury, NY 12804 .}� �r
P: 518-761-8256 .. . .. . Permit# �: ' O�
Tax Map ID 4: I ' 1-2O Permit Fee: $ � ; Invoice #: J_IcI-d'-
TT U
_ —����r� �� Septic Variance? Yes N��o
Project Location: 11
Primary Owner(s)
------ —"— — --- --'
--
Mailing Address
err
Phone & Email
Installer/Builder
Mailing Address
Phone & Email --
Engineer `
Mailing Address ! e_—�q ,[, �
Phone & Email --
Contact Person for Building & Code Compliance: C �/lr! ) Phone:
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)
1981 1991 130 -" Spa or Hot Tub Yes
_ __t— __ Installed? (circle one)
1992-Present 110
PARCEL INFORMATION:
Topography _ F t Rolling Steep Slope %Slope
Soil Nature — Sand _Loam Clay Other
Groundwater _ _ At w iat depth?
Bedrock/Impervious material At hat 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: _
Tank siz gallons (rein. 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: f
C _ — Holding Tank System� :T�_ Le~s_ ota.l;required.ca-pacity? ; tank size — ; #of tanks _
i.i:
NOTES: 1. Alarm system & associ�t . I e�fectr-ic-al-work-must-fie �ng� cted by a Town approved electrical inspection
agency; 2. We will no longer allovt/ 1p
m��'e c vered until4J�acl time as an as-built plan is received and approved.
The installed system must match tqtit'Yayo ��t n'o Iexce,ptions.
Declaration: Any permit or,apprgval-gr�mqd�wf3�ichisbasetl�upon or is granted in reliance upon any material
representation or failure to make- a mafefr0Wf,a`c-�t__6&,ci.rt t. e Vnown by or on behalf of an applicant, shall be void. I
have read the regulations and agree to abide by thes grid afl requirements of the Town of Queensbury Sanitary Sewage
Disposal Ordinance.
e f a n r�0
PRINT NAME: ` DATE:
SIGNATURE: DATE:
Town of Queensbury Duil ing&Code Enfo c ent Revised March 2018