SEP-0277-2021 SEPTIC DISPOSAL PERMIT Office Use Only
A PLICATION - -___-`� Permit#: O Z�'� - n2- I
p is U62 O W E
Permit Fee: $
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APR 2 6 r Invoice#:
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.gueensbury.net TOWN OF QUEENSBURY Septic Variance? Y N
gl!ILDING& CODES
_. -_.. •• Flood Zone? Y
Wetlands? Y �1) Reviewed By:
Project Location:
Tax Map #: Z-+ 4 . }CA _ 1 - 26
RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms: X gallons per =total daily flow
per day bedroom Garbage Grinder Yes N
1980 or older 150 '? Installed? (choose one) ❑
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 Sand ❑ Loam ❑ Clay ❑ Other, explain:
Groundwater At what depth?
Bedrock/Impervious material At what depth?
Domestic Water Supply ❑ Municipal E[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 ! 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:
Alternative System Bed or other type:
Holding Tank System Total required capacity? ; tank size ;
# of tanks
Septic Application Revised April 2021
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant: , �/
Name(s): 3"Cb eit- �I. J NYC �3�'�'`i
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email:
• Primary Owner(s):
Name(s): Nr' Love
Mailing Address, C S/Z: C . At
Cell Phone: Wio JL1 -ID `-7 Land Line:
Email:
Check if all work will be performed by property owner only
• Contractor:
Contact Name(s): V_9_v)d-.0 W Y�
Contractor Trade:
Mailing Address, C/S/Z: -PQk t2r el
Cell Phone: I ' ��f� ' (0'7 9y Land Line:
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:
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 Sewage Disposal Ordinance.
PRINT NAME:
SIGNATURE: �� �� DATE:
Septic Application Revised April 2021