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SEP-0195-2021 Y.:....: .;. .:. ........... ...... office UseDniy. ............ ..... , .. ........ b.5 ::::...... Permit Fee: .. . 742 .. ...P.r..;.3.B8.a.=.y7.R1.o.ad.2:;5:;Q.:.u: e0nisvhirurWeeNsaYs°t�12 -r 8}�0n�4 . 6 g Xw­ .. .J nvoice wu ev Ce FCvod.Zone? Y. wed>B-S.M.C.:PISPICISALPERMIT APPLICATION y' Prn'ect L m GZ {. p D C E9MC To Map...4 Z�l ...... .:..... ..:... TOWf� O�OEJ�Ci�!SBl1RY RESIDENCE INFORMATIONS BUEL©CNG.&C:Oi7ES Yeas.-Built: Gallons #of bedrooms: X gallons per =total daiEy flaw -.. :. per°day .. is bedroom Garbage::G"d' Yes, No w _ _ 198U:oc:older 150 Irrstallecl :(circle cine) =I99130 Y Spa or Hot Tub es. 1981 �io 199�-prese:�t 110 � � ante}nsta a: : circ PAK9.14-INFORIVIATI.QNS. ...... . . ... Topography Flat Rolling Steep�Slope l:Siope _. Sand y 5oi :Nature loam: Cla C}ther, explain;: .... : :Grou ndw_ater. : P... ? .. ..: .. ............................ ro.'k pervous.matra. w a : t:em . ..... Qcimestrc Water Supply Municipal well � hake (if well or lake;Water supply.fro rri any septEe:system:absorption is .......... . .. ft.� . . ......... Percolation Test. Rate: er minute e p: p r inch (test a be completed by a ....... l.:l cens+i:d'engi need architect) .. ............... ...... ... ..... :PRQP.05ED S15TEM::INFQRIIJIATIQN: Tank size: -SO ailons.(Mih. size.1,000 gallons, add 250 gallons for,each:garbage:cylinder.. � .�. g g spa/hdt tub System"'' :Abstrptrcin field:w/# stone Total lerth _4�_ft:;. Each Trencki:: . �......... ft. Seeae : _ ... 5' :. ....:... {� g >Pit w<##3 scone How many::_. lie:.: ... ._. .... Alternative:S.' etn- Bed or other::type: ........ _..�. _. -_ H..oidin Tank''S stem Total:re cared ca acit ? tank size:. Y �# l : Y`. ,. #of tanksaw . ` SeptiCAppljotiop Revised December1020 :. CC?NTACT: INFORMATION .PLEASE PRINT LEGIBLY OR;TYPE,.PLEASE INCLUDE AN:EMAIL ... ... ....... . ... .... •: :A.. :::1ic nt:: � S N.ame(s) ::::: G r1 FVt Wiling Address,C/S/Z:.. .. CeI#:Ptian:e Land.Liner _( ) Erriail: C i • Prirna , O.wner s h Name(sl:: �. -.n r- _. Mailing Address;:C S/Z Zt } . -.Cell:P.hone::_( ) r Land Liner _( Erriail : Check.iifall> ivork will be performed:by pr.®perty owner o * _Contractor:: Coritact`.Na* e(s)s ContractiorTrade IVI 'ilirtg.;Address, C S :. : . . Cell Phvne _( ) Land.line . ( j. Emaih .... ...... *:*:Workers':..O:mwdoturrientat vn mwst be submitted with::this application" ...... •: En ineer: s . ........ ... ... .. Name. s .... .. ...................... .... .... ... . . .. . .. .. . . ...... ... Ma::Iirg;Ad"dress; C/S/Z:. . ... . ........... ..._. _ Cell:Rhon.e :_( ... }: Land:Line: _( Ens#:....... ............ ........ ..... ............ .......__....... ... .. ... Contact;Person:,for Co.mpliance;in;regar-ds.to this project:: - Land Line: .Cell Phone:;:: ........ .. NOTES;'.],"Alarrn;:system::and,associated eleectrical work.must:he nspected by::a`Town:approyed:electrical irispection agency;2.:V11e mill ro Longer allow systems"to be::covered:"until;such time_as.anas.=built:plan.:is received:,-a:nd approved.The instalied.system:must match the:septic:layoufi.on,file-no exceptions 3.;:As b:ai#t drawings:miast:be subimiteed'prior tothe_inspection, if there h"as":been a charigeto>:the submitted" plans.4,'ifi >fgr:an"y reason;'the b�iilding permit application is withdrawn, 30°r'i7 pf:tt e fei:iis reta'ined.:bythe Towwof Queetisb*'I After 1 year`from.the initial application date, 100°l af:th. ee is ret itled:. 1 Dec�ration::Any permit:or approval granted which is .based upon or is grantedin reliance upon any material ..... .:.:......>......:.... . ..:...... ..... representatiori:oi failure to;make amaterial fact oe<circumsfianee lCnovim:by or on behalf:":vf"an;app(icarit;shall be voitl:,#"I ove rep:t,:l b re ulations:and a gee to abide b these and:all re uirements of:the Town caf Que.ensbur" gul g. Y .. Sanitary Sewage Disposal Ordinance:. PR(NT:.NANiE;::.::: l 4 f /. .. ._.: ....:.:.:...:: .;::.:;<:<:.:;:;.>..:;,...:....... .......... _ ............. :.:........:......... ................:.:........:... ..............:......:.: SIGNAL URE..:..:::..... _.:....::::.:::.._..: :.:.... C7AT ................::...... v .. 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