Application SEPTIC DISPOSAL PERMIT office Use Only
APPLICATION 21
Permit C� J � � Z
lam d4: 15 L J - � i'
Permit Fee:$ V J
AUG 3 0 2021 Invoice#: AA /
742 Bay Road,Queensbury,NY 12804 -
P:518.761.8256 www. ueenlbur .n Septic Variance? Y �N
VVN OF QUEENSBURY
BUILDING_&_ CO_DcS Flood Zone? Y
Wetlands? Y Reviewed By:
Project Location: 1'iJ 1"'51- 4 RA
Tax Map #:
RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms: X gallons per =total daily flow
per day bedroom Garbage Grinder Yes No
1980orolder 150 Installed? (choose one)
1981-1991 130 Spa or Hot Tub Yes No
1992-Present 110 n 33cU Installed? (choose one) ❑
i
i
PARCEL INFORMATION:
Topography r44flat Rolling ❑ Steep Slope %Slope
Soil Nature 629and ❑ Loam ❑Clay ❑ Other, explain:
l
Groundwater At what depth? t' IZ-``
Bedrock/Im pervious material At what depth? }7 Z
Domestic Water Supply Rmunicipal ❑Well ❑Lake
(if well or lake, water supply from any septic system absorption is
ft.)
Percolation Test Rate: l •,-zcb per minute per inch (test to be completed by a
licensed engineer/architect)
PROPOSED SYSTEM INFORMATION:
Tank size IWO 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 J 3L ft.; Each Trench ft.
Seepage Pit w/#3 stone How many: :Size:
Alternative System Bed or other type:
F1 Holding Tank System Total required capacity? ; tank size
#of tanks
Septic Application Revised April 2021
. ,
CONTACT INFORMATIOM PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): ,,hA S E e kt,^S Sep},L_)LL c .
l Mailing Address, C/S/2 : -cq (anc� Q c1
Cell Phone: (Sist1KS 7-9pg2 Land Line:
Email: )'W Vnwl`n�n,�CEt,✓ Sep�tc. . to....
• Primary Owner(s):
Name(s):
Mailing Address, C/S/Z: /gam ile.Y R�
Cell Phone:. (S(� 4%!-CK2 4 Land Line:
(I Email: 4-bc"ukx- EskA&n e,
❑ Check if all work will be performed by property owner oniv
• Contractor:
Contact Name(s): ►Yl f,t-NZ,, 14=d SeQk
Contractor Trade:_ SPnf e
Mailing Address, C/S/Z: rti i3Lo,..cL. 4 R�
Cell Phone: / 5eKN s-),- Wry p Land Line:
Email: /o✓L <I '-J ok . cv- ,
"Workers' Comp documentation must be submitted with this application"
• EnQineer(s):
Name(s):i Mailing Address, C/S/Z: �3 Xcr�tvh Avc .
Cell Phone: (Ttsl?'L 72-0 ; V Land Line:
Email:
Contact Person for Compliance in regards to this project: L., U uy ./
Cell Phone: 4? Land Line:
Email: 11Z 2,&t,.r i23I Ana�.c . LV-' ,
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 D' osalOrdinance.
PRINT NAME: L/� �,��
SIGNATURE: DATE: L
Septic Application Revised ApN 2021