SEP-0706-2020 Office Use Only
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SEPTIC DISPOSAL PERMIT APPLICATION Permit#: � ()"Iv0—?p,2ZPermit Fee: Invoice#: 31&,4
- Septic Variance? Yes No
742 Bay Road,queensbury,NY 12804
P:518-761-8256
� ECE0
Tax Map ID-#: 227.10-1-10
NOV 10 2020
Project Location: 43 Bean Road
TOWN! OF QUE 1--{•ISEURY
• Applicant:
Name(s): Keith &Cyndi Leonard
Mailing Address,C/S/Z: 8 Cynthia Circle;Orchard Park, NY 1412T
Cell Phone-:_( 716 sin-6 41— Larid-Line: _ 716 675-5854
Email: keith@mckinlev-liquor.com ,
• Primary Owner(*
Name(s): Airy, LLC
Mailing Address,C/S/Z: 8 Cynthia Circle, Orchard Park,NY 14127
Cell Phone:_( 716_) 510-6241 Land Line: _( 716 1 675-5854
Email:
❑ Check if all workwill be performed by homeowner only
• Contractor:Workers'Comp documentation must be submitted with this application
Contact Name(s): Crandall Excavating(Note:Workman's Comp info on file at Town of Queensbury)
Contractor Trade: Excavation/Site work
Mailing Address,C/S/Z: 61 Wontichnck Hill Road, T.nke. George_NY 1?.R45
Cell Phone:_( 518 1.470-4694 Land Line: _( .51_s ) 793-0431
Email: chriscrandalldigsggmail.com
• Enaineer(sh-
Name(s): JARRETT Engineers.PLLC
Mailing Address, C/S/Z: 12 Eas Washington St.. Glens Falls. NY 12801
Cell Phone:_( ) Land Line: _( 518 ) 792-2907
Email, I.j re na-larrettengineers.com
'Contact Person for Building&,Code Compliance: Keith Leonard
Cell Phone:_( 716 ) 510-6241 Land.Line:_( 716 , ) 675-5854
Email: keith@mckinley-liquor.com
Septic Application Revised Febnran/2019
Or
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
rl992-Present 110 2 110 220
NOTE:2 wastewaters stems serve the house;each system approximately 2± bedrooms use
PARCEL INFORMATION:
Topography Flat Rolling Steep Sloe Varies %Slope
Sol]Nature N/A _Sand Loam _Clay _Other(explain:. .Unknown J.
Groundwater At what depth?
Bedrock/Impervious material At what depth? N/A
Domestic Water Supply _Municipal I Well(if well,water supply from any septic system absorption is ft.)
Percolation Test N/A Rate: per minute per inch(test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR-NEW CONSTRUCTION:
Tank size J.Qffi 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_ N/A 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 slie s#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.Ae-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:
SIGNATURE: DATE: /u-;Z4'
septic Application Revised February 2019