SEP-0190-2021 P
Office Use Only
Permit#: ;W—D i!50 '2fZ-21
Town ofCZccnsbun Permit Fee: �� —
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.gueensburV.net Invoice#:
Flood Zone? Y N Reviewed By:
SEPTIC DISPOSAL PERMIT APPLICATION
Project Location: 16 7i l r Grp. 4-16r-11- I
Inn LF
777
Tax Map#:
TO 13Uf 6F �A;�13 Ry
RESIDENCE INFORMATION: LrcG
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 1-0bo i) Spa or Hot Tub Yes No
1992-Presentt 110 Installed? (circle one)
PARCEL INFORMATION:
Topography Flat Rolling Steep Slope % Slope
Soil Nature Sand Loam Clay Other, explain:
Groundwater At what depth?
Bedrock/Impervious material At w at depth?
Domestic Water Supply _ Municipal —Well _ Lake
(if well or lake, water supply from any septic system absorption is
ft.)
Percolation Test Rate: per minute per inch (test to be completed by a
licensed engineer/architect)
PROPOSED SYSTEM INFORMATION:
Tank size 1-000 gallons (min. size 1,000 gallons, add 250 gallons for each garbage cylinder or
spa/hot tub
System Absorption field w/#2 stone Total length /5 ft.; Each Trench /) ft
Seepage Pit w/#3 stone How many: 3 ; Size: 9-3 t,,-
Alternative System Bed or other type:
Holding Tank System Total required capacity? ; tank size ;
#of tanks
Septic Application Revised December 2020
W`
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): .J C U To
Mailing Address, C/S/Z: r /c t ,� ✓�
Cell Phone:_( ) Land Line:
Email:
• Primary Owner(s):
Name(s):
Mailing Address, C/S/Z:
Cell Phone:_( ) Land Line: _( )
Email:
❑ Check if all work will be performed by property owner only
• Contractor' -
Contact Name(s): 4y
r
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone:_( ) 4 A5' /r am Land Line:
Email:
"Workers' Comp documentation must be submitted with this application**
• Engineer(s)' -
Name(s):
Mailing Address, C/S/Z:
Cell Phone:—,(_) Land Line: _( )
Email:
Contact Person for Compliance in regards to this project: L\0� Ob efk.,. - -hti r✓.
Cell Phone:�_) Land Line:
Email:
NOTES: 1. Alarm system and associated electrical work m::st 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. As-
built drawings must be submitted prior to the inspection;i` there has been a change to the submitted
plans.4. If, for any reason, the building permit application is withdrawn, 30% of the fee is retained by the
Town of Queensbury. After 1 year from the initial application date, 100% of the fee is retained.
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 al! requirements of the Town of Queensbury
Sanitary Sewage Disposal Ordinance.
PRINT NAME: ✓ /G.t �
SIGNATURE: DATE:
Septic Application Revised December 2020
QUEENS
URY
SEp-0190'2021 TOWN N DEPARTMENT
BUILDING DEPARThRENT
301.12-3-5 TOWN OF QUEENSBURY Based on our limited examination,compliance
Todd, Scottwith our comments shall not be construed as
BUILDING & CME1 EBT° indicating the plans end specifications are in
16 mucrest Ave . full compliance with the Building Codes of
Septic Alteration Reviewed BY. New York State.
Residential Sep - _- _ _- - - - �
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