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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 - _- _ _- - - - � ---,:k Date: M Pre e r 16 �1 I 'cC5 � �� C LIH Ol a Ul� 'Tel UO � oC 0 April 05,2021 r avjI J , .•1U�f� a Page 1 of 1 1 �