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SEP-0339-2021 SEPTIC DISPOSAL PERMIT Office Use Only APPLICATION Permit#: UIVII nf0—Irccnshun• Permit Fee: --fAra\J Invoice N: 742 Bay Road,Queensbury,NY 22804 P:518-761-8256 www.gueensburv.net Septic Variance? Y N Flood Zone? Y Wetlands? Y Reviewed B . Project Location: �, �' --a"le. � Tax Map#: ✓�pOi' , �7-� 57 RESIDENCE INFORMATION: Year Built Gallons #of bedrooms: X gallons per =total daily flow per day bedroom Garbage Grinder Yes No 1980 or older 150 Installed? (choose one) ❑ ❑ 1981-1991 130 Spa or Hot Tub Yes No 1992-Present 1 110 =� ho IInstalled? (choose one) ❑ ❑ PARCEL INFORMATION: Topography ❑ Flat Rolling ❑ Steep Slope % Slope Soil Nature Sand ElLoam ❑ Clay ❑ Other, explain: Groundwater At what depth? Bedrock/Impervious material At what 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: ,5 irr lcc:�/ ,�• ;,,,�// �z G t r'S Tank size 4022 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 ft.; Each Trench ft. Seepage Pit w/#3 stone How many: ; Size: X Oi Alternative System Bed or other type: Holding Tank System Total required capacity? : tank size ; #of tanks Sell-1�0 Septic Application fef e,-.5 Revised April 2021 CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL • Applicant: . Mailing Address, CJSJZ: t a e. ur izz -a Z-66� Cell Phone• 70-7 Land Liner Email: -��� _9?�o�c'.s i� �5�`►�'��Sr < ��v Primar Owner s Name(s)• Mailing Address, C/S/Z: Z, 4 •e_ 0 Cell Phoz - 27 Lan Line: Email. �o^� 3� y,,,,�,,; 1 ❑ Check if all work will be performed by property owner only • Contractor: Contact Narrie(s): r , ! Contractor Trade: <e ;G 115�r 1—hr 4 Mailing Address, C/S/Z: •°3c�� ��'�<S©. .ri." -� f���'6 Cell Phone: .r 0- Land Line: Email:t4 a L N c� r-' y **Workers' Comp documentation must be submitted with this application** • Engineer(s): Name(s): Mailing Address, C/SJZ: Cell Phone: Land Line: Email: Contact Person for Compliance in regards to this project: Cell Phone: Land Line:. Email: NOTES: 1. Alarm system and associated electrical work must 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, if 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 all requirements of the Town of Queensbury Sanitary Sewag isposalOr ' ce. PRINT NAME: ,ri.0 SIGNATURE: DATE: Septic Application Revised April 2021 ►. SEPTIC DISPOSAL PERMIT Office Use Only 5 APPLICATION Permit#: 5—' aa35--X2-1 Town ofQuccnsbory Permit Fee:$ Invoice#: ^' 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.aueensbury.net Septic Variance? Y N Flood Zone? Y N Wetlands? Y N Project Location: Z u�,�' D Tax Map #: MAY 0 9 2021 RESIDENCE INFORMATION: TOWN OF QUEENSBURY Year Built Gallons #of bedrooms: X gallons per =total daily flow BUILDING&CODES per day bedroom Garbage Grinder Yes No 1980 or older 150 Installed? (choose one) ❑ Jq 1981-1991 130 Spa or Hot Tub Yes No 1992-Present 110 Installed? (choose one) ❑ PARCEL INFORMATION: Topography ❑ Flat Rolling ❑ Steep Slope % Slope Soil Nature �-?5Sand ❑ Loam ❑ Clay ❑ Other, explain: Groundwater At what depth? Bedrock/Impervious material At what depth? Domestic Water Supply /lunicipal ❑ 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 00 gallons (min. size 1,000 gallons, add 250 gallons for each garbage cylinder or spa/hot tub Jrr4tl--, ' System Absorption field w/#2 stone Total length 1. O ft.; Each Trench -) ft. A a s H ota I require capacity. ; tank size ; Septic Application Application Revised April 2021 CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL • Applicant' ° r Name(s): Mailing Address, C/S/Z: 0 Cell Phone: 5W Z57:; 0-7 Land Line: :�;/P' Email: d IeCL e4;1 a1 r.-J J coPv, • Primary Owner Name(s): Mailing Address,.C/S/Z:- �Z - jd�c4.�� • . (�1 `�� � �''`�rr, - i2�30 °f Cell Phoq& ; Land Line: Email: �,, p r ; i/ ury, Cfiec'k:if alfwork,.will;be°performed by property owner only - c' iil;a • Contractor, Contact Name(s): Contractor Trade: ^� Mailing Address, Cell Phone, Land Line: �/� ��; ���a 'A 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: fir+ al✓`�� � 1 - Cell Phon : / Z,%27— 7AD1 Land Line: A9 4,0'g _ Email: C111,4r?;> Gkdljzc I_t d o4,P/e,,- G�1v^ NOTES: 1. Alarm system and associated electrical work must 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, if 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 orfailure 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 all requirements of the Town of Queensbury Sanitary Sewage isposal Ordinance. PRINT NAME: ,GrsT / f�✓'v� SIGNATURE: _�--• DATE: Septic Application Revised April 2021