SEP-0414-2021 k :
office Use bnly.:
;. >. Permit#: �
......... ..
.ry. Perm e Permit Fee:$
......:...:742 Bay Road;Queensbpry;:NY'22804.
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:: ? 5187�1-8256.:wrniuti+;gueenshurj�net Invoice#:
F(obd.Zone? Y N ReViewedBy:
SEP-TIC:DISPOSAL PERMIT APPLICATION
V
Y�
....t�
Project Lacation
Tax_Mai #: ..
0 1 2021
TOWN OF QUEENSBURY
BUILDING& CODES
total daiiy flaw yµ
Year::i3uiitedroorns X:` allgm per ..
per day. M bedroom Garbage Grinder Yes No
,.
1980.or older 150. .. ..:: �. Installi;d?.:lcircCe one} .
�_—: ...
19814991 130' Spa':ofHot:TU -Yes o
.......
1992=Rrese:nt: 110`
Installetl!?::�circFe:ane}
PARCEL INFORMATION:..
Topography Flat Rolling Steep$iop'e 1 Slope,
.Soil Nature' Sand loam Cla Other .ex lain,
Y
Groundwater: At what;.de th?
......
- ::9e' ..roc,: ;fmPervious_:mater.i:al . .At;what depth?
. ...... .... ...
Dq est.ic:.Water:Su.pply 117lunici al _Well _. a{ce
(i well or lake;water suppl.yfrom any septic system absorption:is:
ft.)
Percolation Test Rate: per.minute:per finch ( est; o be completed by a
...
licensed:engineer/architect)
_I ...
PROP.OSED:SI STEM INI=t)RNIATIO.N:
- .....
Tank size gallons :(min. size 1,004gall.ons; add 250 gallons for:each:garbage cylinder ar
spa/hot tub
System Absorption field w #Z store Total I:ength ft.; Each Trench ft,
See a e<Pt w #3:stone How'may:. ;;Size:
p :
g..
Alternative:5.ystem. Bed or other:type.:
--
H:QldingTa_nk:'System Total.:required capacity? ;tanksize. .� ...
tanks
SeptiuAppikatiom Revises!Decem6 ... ...
C QT.jNFORlV1ATl.QN .PLEASE PRINT:LEGIBLYDR'.TYPE,.:PLEASE;INCLLI,DE;AN. ENTAIL
Applicant
Names) ` I rN V 1 CQS
i3
Mailin 'Address, 'GIs/z: / .
C:ellPhane Land Line:. _(
4.
Emaw
• p iary{owner
Name. s
Mailrig'Address ;CIS/Z r`
..Cell Phorie" Land Liner
Emai ,
Check.if,A W.&kwill be.performed by property:owner only,
. *: :.Contractor::
Contact:Name(5j � � lk)(Ut In-
to tractorTrade C
Mailing-Address;;C:.S Z::
Cell: Land:Line:Cell:Phone:_( }'.... _�Slf }
Einar : .
...... .
Worker ' Cemp documentation .must be;submitted withahis; plcation*
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• Engineer $ :
. .........
Name(s): ....
Mailing Address, C.S/Z: . .
Cell:Phonel. .(. } Land-:Liner ( )
Email: . . . . _ ....._._.
contact:Person tottompliance in regards.tdlhis project: .... . ..
Land Line: .. ..
CeII Phone:. (.... . ....j:.. -. ( }.
Email::
:'NOTES: 1..Alarm;;system:and associated electrical work.must be1rispected:by a Town'approved:electrical
inspeetiorn::agency;2..vV.e urill i o longer allow systems to be:covered.until:sucli:time as an as built plan is
re.celved and':approved.The installed system:must match.the:sep ic:.layout on.:file--.no:.exceptions.3:.;As-
builtAra.wings:must=.be submitted prior to the:inspection; if there has been:changeao:the submitted
plans::4. If;:far:.any reason, the:building permit application is withdrawn;3Q a ofi:th'e free:is::reCained:.by the
Town.of.Queensbury..After 1 year from the initial:application date, 100"Yo:of the:fee:is retained..
:Declaration: Anypermit::ora : ;royal, ranted:which:is::based:upon:or is. ranted in;reliance u on an ;material
pp g. g P y
representation or failure to rnal�e a::material factor circumstance krtown.by or on behalf of an appiicar►t,shall be
Void<:1.;hav0.read:the regulations and:agree to abide by these and,all requirements of the T6Wh:of Queensbury
SanitarySewage:I7is asal Ordinance,:
� pp
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..:PRINT:NAM
L-.
.:::SIGNATURE:'.:::.>..: : . pATE. ::
Septic Application: Revised,December 2020