SEP-0065-2021 e.On y;:
` : : : `: P:ermit:#_ P-• 00� - 202�
Permit Fee:$..e)
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742 Bay Road;Queensbury,NY.12804;
i8=7 1�8LS.... nrui aueensburj�net
.... ........ Invoice#:.. 3?J $
Flood Zone? Y- N Reviewed!D :PS
....... SAL PE 9 'APPLICATION
Projec#:Location:
:
-pur o I E C E 0 V E
UU
Tax:Map:..
_ FEB 17 2021
TOWN OF QUEENSBURY
BUILDING&CODES
RE5IQ:ENCE INFORN-ATIONs
g P Y
Year Built .Gallons #of bedrooms. X allvns er =total doll flow
per day. is bedroom G°arbage.Grinder: Yes;
--
1980::0`r:older 'I'S Installed?:(circle one)..
. ....
198;1-1991. 1 :d: T Spa or'H,ot Tub: Yes o
?
1992=Present: 110
..Installed {+circle arte�rr nn
PARCEL:INFORMATION:
Topography ;Flat Rolling _____,Steep Slope l Slo e.,. P
SoilNature Sand Loam. Clay - Qther, i.xp:lain,:
13
Groundwater At what de th?
... .......
" :Bedrock/Impervi;ous.materral .. .At.; '.hat.depth?
Domestie'NVatOr`—apply unicipaI !Well Lake
(if well or lake, water supply_from any septtcaystem absorptio_n:is.:
_... .... ft.}
Per co(ation:Test Rate; I- er miiriute.: er inch p. p. . . test:to becampleted by a
l.:licensed engineer/architect)
PROP.OSED`5Y5TEM::INFURIiJIATIOhI:
Tanksize gallons min. size 1,000 gallons, add 250 gallons far each. arba e c lender or
.. : .... . ...
s.pa/hot tub
System: Absorption field w #2 stone Total Iengtl ft ; Each Trench I.
p g. How many:See a e pit w :#3 stone _ ;Sic:; ..
tyAlterrative.5yste e rpe_
Ho ding Tank System Total required capacity: ;lank:size
j
#of tanks..
..... ... . . . . ......
Septir.Applicat'aon Revised"December 2020,
,::....... ..
:.. .
CONTACT:INFORMATION .PLEA°SE PRINT LEGIBLY OR.TYPE°, PLEASE:.INCLUbt AN: EMAIL
• ApR1icant: t
Name($):.. 2 k.n 34w\ 1(: S
ell!P ondress:.lf S/z: La
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n V�
e.
L
�.. .. . n� Land Line:
.Primary O.wner(s}:
Name
( }. . r..\., N 1.'e
Mailing Address;.G Sf Zr ,�S _
Celt Phone::_( 1. } .`7�(�� c�9'-l� Land:Liner ( )
Emai,
� Check ill~all work,yv. be performed:by property owner.only
•: ::Contractor:.
Contact Names}
Contractor;Trad..et
IYla;ilirtg-;Address;C%S/Z:..
.........
Land Line: _( }
Email:'.
W 'rker ; Com d:cumentation must:be submitted with this oWication
o . p
Engineer :
Name(s);: .
... .... ...... ...
:.:.:. ..g:;.A:. .
.... .. .:. .... ..... ......... ..
Maillin ddress► C/S Z:... ...
Cell:P:hone ( }: Land Line: . ...... .
Email:_
Cohoti Person:for Compliance'in'regards:to:this project: 1YIL� �,
CeII Phone: Land Line: .4 y
Email: Lip MM -
t
NOTES:.. :Alarm.system.and associated electrical:v+fork.mus#:be::"inspectedby:a:.iown:appraved:efectrical
inspection agency;2..Wei Il no.longer all.ow_systems.to be covered until such:time_as.an as=built plan::is
rece Wed:and':approved.The installed.system: rust mafch the.:septic:.Iayout on;:file--.no exceptions. 3:..As-
baiit'drawings must be subrtitted'prior to the,inspection; if there has been:a`crtange:to.tte submitted
plans::If, for any reason, the building permit appl,icotion is-withdrawn,.30%of.the ee:is::retained:by. the
Town.bf Queensbury'. After 1 year from the initial appl ication.date, 100%of:the fee-is retainer.
declaration: An:y permit:or approval.granted which is.based.upon,or is granted,in.:.reliance,:upon any material
representation or fMIUr-to:rnak6 a.mateeial fact orci�cumstance knovwn:byor on behalf of an.applicant;shall be:
Void',:l.have read.the regulations:and:agree.to abide by these and ail;requirements:of thel6wn if Queenskiury
San tary;5ewage:0isposal;Ordinance.
_-
si�NAruRE: oAii ': - '< >`11; ......
Septic ApplItaLitin: Revised;December 2020