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SEP-0277-2021 SEPTIC DISPOSAL PERMIT Office Use Only A PLICATION - -___-`� Permit#: O Z�'� - n2- I p is U62 O W E Permit Fee: $ I_ 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