8200 TOWN OF QUEENSBURY
BUILDING &ZONING DEPARTMENT
SEWAGF DISPOSAL PERMIT APPLICATION
1. Owner' s Name /-7,1 1��/ - C0 /� �}"/1 -�b� !> e'S6,9-ec)DDim nmiv1le
-CAst-e S -`� 6��J /v 4-P r 110 exe 4‘ I \.. e c-s'p_
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A6w ajO l�,C ) Telephone No./"-2 d/-e //VJ 123
2. Property location ( /. . , 0
3 . Name of person or firm responsible for installing system .
70,1" `-1 ALL)e // Telephone No. / /—,2jf (if
Address /
4. Number of bedrooms (residential buildings only)
5. Daily flow gallons/day
6. Septic tank capacity gallons
7. Topography: (2ID rolling, steep.
% of slope
8 . Nature of soil and depth <.a
/ •
9. If ground water, bedrock or impervious material is apparent at what
depth does it begin? ft.
10. Percolation test: is required
B is not required
C If required what is the rate , minutes/inch
11. Water supply: muniipal, well, other
12. Type of system proposed: drywell,(ile fieli other
:Any contractor, corporation, individual, etc. engaged in the construction
of a sanitary sewage disposal system who covers the same before inspection,
does not have an approved permit, or varies from the approved application
will be subject to a penalty of $250 as provided for in Section 6 . 010 of the
Queensbury Sanitary Sewage Ordinance.
Date ( . D _ `- . e=?
signat{�re of applicant
V
On separate sheet of paper submit a. diagram " the proposed septic system
with all dimensions, including distance from any structure, distance from
property line and domestic water supply, etc. Include all dimensions of
the system itself TOWN OF QUEEN$au.—C� C � d
s �G � rl
Form 3-82 �i7‘) 2.0 a, 7/ e�Q,. 6a:P.I. 690 . "irk-1113��j�
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