SEP-0406-2021 .. ...;:;.:: _..
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.,K£4 ... ....
Mee Use:Only:
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P rmit:#:�—
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Permit Fee:$..
742 Ba Road Queensbu.
rY;NY°12804
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FI od.Zone? Y N 'evfewied.
SEPTICQISPOSAL;PERMIT APPLICATIONS
Project location: (�
nn ECE0IC
TaxMap I '� JUN 01 2021
TOWN OF QUEENSBURY
BUILDING&COMES
Year:;Built Gallons #of.:bedrooms ;X gallons pef =total daily flaw
Garb
per: lay. :: bedroom ge:GPn..er: Yes, Na
1980:.orolder 150 Installetl?.::csrcle aie).
1981=1991: 130 Spa or Hot Tub Yes No
:1992.-Pmsent: '110 __..
Insfialfed '(circle no)
PARCEL INFQRMATION
Flat Rolling Stee Slo e Topography:. p`::..; p. .. ::.... : . °l Slope;
Soil Nature Sand Loam Clay 4ther,.explain
Groundwater At.what:depth?
Bedrock/lmpervious.mtertal .. .At hat..depth?
.0omestic::lNater Supply:, un cipal _well .... Lake
{if well or lake, water supply from ar y septic system absorption:is;
ft.}
_ p ... ._ Y
Percolat[on'Test: Rate:
. . ..:... . ...
per:mtnute per inch (test>:to:. O'cam ike_ :b' a
...
_._..... ;..licensed engineer architect
P;ROPOSED::SYSTEM INFORMA-TION0
T k sk.:siie> : .�_ga .ons . mrn. size. ,O. .O.gallons a ga. dins ;Q:r eac :gar age-.cy In..er or
.... :spa/tottub
System Absarption.field u4 � one Total length ��ft:;. Each Trel
( ;:Size;.
.... . .See a e Pit w #3 stone Houv;m:any;.
Aiterriative:System Bed or other type;
Holding Tank S,ystern Total required capacity? tanksize
# of tanks.
eptic:Application Revised.Decern6er,2020, q.
..
........... . .. ... .............. .
CONTACT:INFORIVIATi ON:.PLEASE:PR I NT.LEGIBLY OR:TYPE,-PLEASE:IN.CLUDE AN:"EMAIL
A licant ;
Names)
Mailing..Address C.S/Z..
�5—
Ceil Phone..:: — _( ) "
}: Land Liner
Ema�t YV1 Cz— - -dam(i
:Pr:i m a ry:Own a r(s)
N..ame{s} dz. . . .
.......... .
Wjling Add.Tess;C/SJZ uee-v)S . u .
Cell'Phone:-( } Land.Line;:
Ern6il::
171;Check if all wot.Vwiii be.performed by property:owner onl
•:: :.Contractor-..
:.Contact Name Q_YS
Contractor Trade: L
1Vlailing Address;:"C/S
Cell Phone:_( } Land Line:: _ g (C�}`?
Ernai.,
*.*Workers.'::Comp.documentation must be.submitte.d with this::appiication' *
• fnQineer s :
Name(s): ....
Mailing;Addeess,
Cell Rhon.e:._( .. } Land:tine:: . . . . .. . .. .....
.....
Email:....
Centaci:Person fot'Co.rriiiliance:in'r..egards to this project::
CeII Rhone: (..'...�1-.. . ...Land Line:
Emaif:
NOTES..' I. Alarm,system::and, associated:electrical work must be:inspeet:ed by:a:Town approved electrical
inspection agency, 2;:We will no:longer allow systems to be covered.�unt-1 such time- art as bt ilt:'plan is
received:and.approved.The. installed system.must match the septicJavout:on,file--.no:exceptions. 3.As--
built draw' ings.must:be submitted'prior°to the:-inspection; if there has been.a:change 16 fhe submitted
pJans :4.'tfr`fvr:an.y reasons°the:bui.l:ding-permit apPliaation is withdrawn, 30 a'-of:the.fee:is.retainedb the
T0Wh of Queensbury..After 1 year from the initial application date, 100°10 of the fee is retained.
nyrmo olgranted vhichs.basd uponor is granted n re iaceupo any materiaDecaratib A r v :
representation or falluce:to.make a.material fact or circumstance known by°or:on�behalf of an:applicant,shall be:
v*4 :have read the uatonsandagre.tobibythese andal requirements'o th'e,T6,, :* Queensburyt
Sanitary Sewage Disposal:ordinance,.
....PRINT::NAME:..:.:�' 1
»< J.
<: DENTURE:` DATE
septic,Appiieui6m Revised December 2020*
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