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SEP-0044-2021 :r r IX Officeuse Only: :: : :; c E .. ......... pn .r V . .. . ...... D ee:$ :::;:::::742 Bad 1Rcad,,Queeitshury,NY 1404. 2021 .. Pr518-Tb1=8.256:'ivviww:queensa FEB 0 urrret I V e TOWN OF QUEENS (ff d...:ne? Y O Reviewed By{, _ ; EPTIC DISPOSAL'PERM1 IgCrD s Project Location: J140 14-t-S - ML r� �,^Q;.(-C�j'1�C lJ� Tax Map RESIQEN:CE:INFQRMATION: Year uilc Gallons #of bedrooms: X gallons per =total daily flow per day. bedroom Garbage:Grinder Yes: .. o 1980:.or:.oldee 150 Installed?.(cimle:c:ne} 1981=1991: lag Spa:`or Hot°Tu es o 1992-Present 1'lU InstaUed? acircle_:anei _.— PAR. tEL.INF0RMATI0N: Topograp y Fat Ro in Steep:Slope % Slope: g Soil.Nature Sand ..... Loam Cray Other, exp.laih., Gro:undtiater: ? ....... At what depth. ti A Bedroe_k/Impervious material, Atobot depth. ,Nelf Qome:iti.c-Water.sup p1: Mdnicipal Well `Lake (if well or lake,Water suppl.tfrom any septic system absorption is; ft.) Percolation Test Rate: 1 �—u . per:minute' per inch (test to be cornmpleted:by a ...... ....i. licensed 6tigineer/architect) PRO P©SED:SYSTIkM INFORMATION Tank.:size od gallons: min. size 1.00O.gallons, add 86 gallons for:,each:°garbage_;cylinder or spa hattub System :Abst rpticin fielr 'W #2 stone Total I; ngtfi� ft ; Each:Trench: ........ ft... See a Pi ;HOW`hany:.. pag..>.:�t W>#3atone ;Size:, Alternative System Bed or other type; Holding Tank System Total required capacity? tan size_ .. . , �, - #of tanks -.:; 2 IS�-t -�a-r� . W1\\ aS:a.: . Septic Application Revisedbecember.lak ....... ... .. ............ . CONTACT INFORMAVON .PLEASE:PRINT LEGIBLY OR TYPE, PLEASE::INCLU,DE AN EMAIL r" ... wrerr.wi - .... .... •: Aoolkant :i Name(s):: :::..... . l �S I.. iIii g.Addiess.CIS/Z . 1_.owes l rrer, Cyue�ers �r S+- :C.ell F'hi3rte:�` }' f'D l — ��Lo 5 Land Line: _( 5113 }�ci�—�t� `EirTa}f A. Primar :+Owners : Name.(sl:,.: Y1re S Mailri :Address;:C/S/Z V�2 . oure� n CUTA-c--r' u_r.... .:... .... .... ....... CeII Phone:_(-5.18 Land fine;: g7i'o Emat,I >] Check if.all work will be performed by property owner only •: :Co. ntractor:; Contac. arrie(sj.; Corwtracto..r.Trade. Mailing_Address,.Cf.S/Z:: _ .:. . Cell-Phone:_( } Land Line: _( Email: . ..... ..... **UVorker ' Comp documentation must be submitted with this-applicati.o . • Engineer. s ...:........ M.gJ.1 ng Address, C/S/Z: . . . . . .. .... Cel#:Phone:_(. } Land:Line: _ Einar# ---- ........ .........— Ciintact°:Persori`for;Compliance"in regards'to:this projeet: .. . Land Line: r } .. ... .. cell Phone: :(. .:.. . 1 . _. ....:....: Email: NOTES.1;.AlarM:;system:and associated:electrical work:must.be.inspected by a:Town:approved:electrical inspection::agency, :.,We Will no longer allavi t stehit to be covered until sucl�.time as an.as built:plan.is. received and::approved.The installe.daystem::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 fo the submitted plan$:::4. t"for:any reasart,fil7e:building permit application,is withdrawn;.30%of`th'e-fee:is.retained:.by the Town.of QueensbWry:;Afti?r 1 j+oar`frcm the in#tial.appl#cation .date, 100nf of the fee is retained... Declaration::An:y:permit:or approval granted which is based upon is.grunted in reliance:;upon any.material .....,:. representation or failure to make a material factor circumstance known by.or on.behalf of an:applicant;shall be void.i,ThaY6 read:the regulations:artd;aigree::ta abide by these and ail,requirements of the:Towri'i f:Queensbury Sanitary Sewage Disposal Ordinance; DATA '.:,:..:::"' SepticApp(kkon Revised December2620 2/3/2021 Town of Queensbury Interactive Mapper Town fX f"ueensbury Interactive Mapper FE.1 ER z 0 BUIUOIW� 3 W eN%A 11 lit, ewe 4*� t. 01,VNER BRA ,4u . ACr i. -7 4 'ER: R0BERTDbARRiS' cO1?D"l' sjj T'k vn V Location -73,—, 30, 4 https:/Iqbygis.queensbury.net/webapp/default.html?pid=301.17-1-26 1/2 Z'z PVI'ap,�� �„ /C} L 'J" R L �A IN$1171 tt RR! C S I L AS,'BUT 16�rlll v. t L -ont- 'id 8. _­"R k_11J. ti,t "Tw 'c. lNi All ap.04% Q*' in- t' r, Flc lil�c y 'o."" r4 r, all :04 ir, zk� 1� 'Ass- Q ER: R)OER • $A" -mww https://qt) R 7 ygi,,.queeiis[)tjry.net/w(,bapp/defaLlIt.titnil?pid=301.17-1-26 1/2