SEP-0196-2022 f
SEPTIC DISPOSAL PERMIT Office Use Only
APPLICATION Permit#:
ft� -L r ��
Town ofCZccnsbury E C E 9 W FE Permit Fee:$
D '
Invoice#:
742 Bay Road,Queensbury,NY 128 4 �V ���
0
P:518-761-8256 www.gueensbury. `22 Septic Variance? Y N
L
WN OF OUEENSGUHY Flood Zone? Y N
BUILDING dr=S Wetlands? Y Reviewed Bq!�
Project Location: 0 C!]A C� Vim/
Tax Map #:
RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms: X gallons per =total daily flow
per day bedroom Garbage Grinder Yes No
1980 or older 150 Installed? (choose one) ❑ ❑
1981-1991 130 Spa or Hot Tub Yes No
1992-Present 110 Installed? (choose one) ❑ ❑
PARCEL INFO ION:
Topography Flat Rolling --- -j] Steep Slope 1 Slope
Soil Nature Sand ❑ Loam ❑ Clay ❑ Other, explain:
Groundwater At what depth?
Bedrock/Impervious material At vohat depth?
Domestic Water Supply ZMUnicipal ❑ 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 06 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): (\A cA r'1C S�k,44N l
Mailing Address, C/S/Z: 6-6 (Q 04 4,11/ d�e�-
Cell Phone: G-?? 00t 6S7 11 Liand Line: •7 6 2-7)
Email: Mc--<:77
• Primary Owners :
Name(s):
Mailing Address, C/S/Z: I M
s �v;-v�oYl,�✓
Cell Phone: 631 JDt a71'7 U,Land Line:
Email:
❑ Check if all work will be performed by property owner only
• Contractor:
Contact,Name(s): til�
Contractor Trade. -e,lA I zil
Mailing Address, C/S/Z:
Cell Phone: 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: ' A
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..) have read the regulations and agree to abide by these and all requirements of the Town of Queensbury
Sanitary Sewage Disposal Ordinance.
PRINT NAME: .1
SIGNATURE: DATE:
Septic Application Revised April 2021
TOWN OF QUEENSBURY
BUILDING DEPARTMENT _�- ------�- �}`
Ba;ed on our.limited examination compliant le
E �
LlSfli OJ comments Shrill not be G]flStrlleCi tic-
indicaur;g the plans and �oecifica,ions are in �� �
full cornpltance With the lBuiiding Cod: s of --
kiew Ycrh Stale.
D S1 W [�G�" ' ��
- � s
i
Q S-e
rfF,
Fe i q�
- _
N
�
� o
—� c
Reviewed By: W C 1W
Date:
6-0
V L rid rl Q U
fD1 �� X C
0
—� MCd" U
TOWN OF QUEENSBURY.
BUILDING DEPARTMENT a--
Bosed on our,limited examination,coxil. liane aLf i
tiVit^'oUC-comments siisli not be construed es °
indicating plans'a;:d sgpcificra ions ur8 in 9 G.
:uN..co;,��i;an -e ;viLh flip Building Goc es of
1.. New Yo l;State ,
.C.A �. (:.�,¢ .G,•_ IJ-.G,: .: _ ` ; t;S'�t.- ,p�.l: :S:I' -t, (;,�:G.S� " ( U ''�LN�•�
vv � y 11
0F. .sck
e�'sl►v1 Savo
S•e phi c: -C,a� 1�
b sv0, o
afzll s
�i
I
t: 3 ..6cc l Sim
--------
D. _: iJl�'J 1�U� SDI a0
�- -C J�
�. fO'k/V� OF CCU E
NG
B 55
c
� t AS UIL
y..
Mo
.
LA
dr� _ Iw
c��
i' �O O