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SEP-0359-2021 ......... ::."... .... .. Office tlse=C?nly: ..... Permit Fee.$ ... 7+3Z Bay Roads QUeensburY::NY:32804. a P;5f8�76.1�8256 ww%fi ueensF2ur rrei x Invoice.#: Flood Zone Y. N e:uiewed By: SEPTIC:DISPOSAL`PERMIT:APPLICATItN �p Pro'ect �Yl a.. .:avocation: E C E n#of tanks rn s' D Tax Ma.wt . MAY 14 2021 TOWN OF QUEENSSURY RESIQENCE::INFQRIIATI©N: BUILDING&CODE Year::Built:` Lallans #o'be drooms-. N galians der =fofal I'd' if flav�t pee day, bedroom Gar age,_G:rin er. Yes. No . :1980.bvoider 1S0 installed?.i'(ciecle;ono) T981r199130 Spa or Hot:Titb Yes `�:992-Present 1.10 _.. Installed:: circlearie) :PARCEL:INFQRMATION: . `Topogirap. y Flat Rolling St8epASlop6. to Slope: SoI :Nature Sand Loam: Clay Other, ezpla'in Grour►dwater: At,.what depth? : .. - Bedrock%Impery ous.material At--w at cleptki? ":: .:...... .. ........... . .. .... _.._...... D.©mestic:Water:Sil,ppljr Municipal Well': Lake _ .. If v►reI or lake uuater'sup p►y from anyseptit system absorption is: ft.) Percolation.Test Rate: or minute per inch testl ,be-com feted b a p p Y. : ;.:licensed engi;neerJarchitect} .... . . .._. .. PROPQSED.:51f'STIIN FtQRi1�lATIQhI. _� Tank.:sibe a0 g._ .,ons(min. size.1,.000.gall.o.ns; add 250 gali�ans for:each:garbage::cylind.er or spa hottub . .... : : .System ' :Absorption field:w #2 store Total 16 gtii ft'; Each Trench`: ft.: How:man _, Size:Seepage:Pit'v. , .3 tone y Alternative:System Bed or ather..:type- HoIdin Tank S stem Total.re: u�red ca aat ? tank size.. .. g y E Y Septic Application Revised December3020 .....:.... .. ... .............. .......... CONTACT:�INFORMATI:O.N: PLEASE:PRINT:LEGIBLY CR TYPE, PLEASE::INCLU,DE AN EMAIL ... ....... • Applicant: f Name s Mailing Adtlress; C/S/Z:: 1s�� _.64: Land Line-- Emafk rn c g. C' " •'::: Rr:imaryd er s ; 1 ........ ........ ..... { }.... Ma'illri Address.:C/sJZ r�-• .. 2.f�� liY Land:Line;: _( } Emal.i : 0:Check iif;all-w.dt.k will be.performed b: ro .e:` :owner'and yp p �Y ; .: : *: :Contractor:: C.orita fi N :me. s �J S c3 �� �YZ� cn e r yI ce Co.rrtractor.Trade. � G wilinlg Address,;C .S Z:. , :: ..�Y' Y7LL CeII Phone _( } j �I-� -{Cp land Line:: bL l � Email: . C **Workers' Comp..documentation must be;submitted:.With this apOlication** • Engineer: s Name:N: . . ... .............:... . Ma:fling Address,.C/S/Z:_ Cell Phone:._(. .'. } Land:Line:; {. .... .... }....... ...... Em' all: .................... __. Contacti PCrsbrtf.Or Compliance:in:regaCds.to'this project; .............. ... ._ .. Land Line: CeIG Phone:�,.. .�} . ...:.. Email` NOTES; -1,,Alarm.system::and asso.clated:'ele:ctrical:work must.be;.inspected:by..a:Town.:ap,proved:el'ectr.ical inspection:agericy, 2..1J11e will no:longer allouv systems.to be covered.unti!such time'as an as-built:.plan.:is received arid::approved.rhe. installed system;must match:the:septie layout on:file•-no::exceptions. 3.:As-- buiftdraw ngs.must::be s..bmitted.:pdbt to the,insp.etti6m if there has.beeri:.a change to the submitted . plait:* It.for..any rea..son the b.0di.ng permit application is-withdrawn,;3Q%.Of':'h fee:is retained key the TOWh...fQueer�sbur'y.:After 1 year°from the initial appl cationi date, 100 of the:fee is retained... .::Decli�ration::Any:.:permit;or appr..oval granted which is based':upon:or is granted in mliance.upon an.y.material representation or#allure to:make:a:material fact or circuinstan a known by or on:behalf'of an.applicant,shall he void;!:''t ave:read the regul.0ons and agree to abide by these arid_all:r..equiremerits:of the Town:of Queembury. Sanita ry,Sewage:.Disposal.Ordinance. -..PRfNT::NAME::- '11 1�GJL-1P1. �.`.... ::.. . _ ;:::. Sl��NATUW .:.` ..:' ;:::.. "' �� DATE Septit.AppliCation. Revised.December 2620