98-167 Application for SEPTIC DISPOSAL PERMIT
Town of Queensbury Permit No.
Dept_ of Community Development --
Building & Codes Office -, , _ ee Paid Is
742 Bay Road
Queensbury, NY 12804 APR 21
Location of property for installation: t '
! /ry1T154
Property Owner's Name: /"1*1 A r i o ' A C , A
Property Owner's Mailing Address: ! I a C ' J
Installer's Name: 1r� % ; G Phone
Number of bedrooms (if residential) : _ Total daily flow:
(residential - compute 0 150 gaLAxirm.)
Topography: t, rolling, steep slope % of slope
Soil Nature: sand, loam, clay, other / depth:
Ground water: at what depth?m feet 1 Bedrock or Impervious Material: at what depth? . feet
Percolation test: A. not required, required rate min, per inch ]
Domestic water supply: Ymunicipal, well, ocher
If domestic water supply is a WELL, water supply from any septic absorption is 4 feet.
PROPOSED SYSTEM rr ► S ! r ^
Septic tanke Q0 gallon (minimum size: 1 ,000 Bail..)
Tile field: each trench 0 feet I Total system length: d feet
Seepage pit(s): number of �} / size each.: ft. by ft.
Size of stone to be used: # I depth or thickness - feet
HOLDING TANK SYSTEM: (if required)
Number of tanks: Size of each.: gallons
Alamo system and associated electrical work to be inspected by a certifsed agency.
For your protection, please note that pursuant. to Section 136-29 of the Code of the Town of Queensbury, any permit or
approval granted which is based upon or is granted in reliance upon any material misrepresentation or failure to make a
matenat fact or cimumstance known by or on behalf of an applicant, shall be void.
l have read the regulations with respect to this application and agree to abide by these and all requirements/of the 'town of
Qcyee�}3ury sanitary Sewage Disposal C}�aiimanc �! r/
Signature of responsible person: Date:
�o APR 22 1998 Ry
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TOWN OF QUEEKSBURY aaa
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BUILDINRG A CODE ENFORCEMENT
742 Bay Road
Queensbury NY 12804
(518) 761-8256
SEPTIC 7SAL SYSTEM NSPECTIONI
Name (!�C[7fi��
Location ,r
Date Permit # " r�� -
010
SOIL TYP an Loam- Clay-
Results of Perc 7a ion Test-
( if appli b1e Rat -Minute/ Inch
TYPE OF SY
r
ABSORPTION EL T tat Length, o_
Length of eac ren h 5
Depth of trenc
Size of stone
SEEPAGE PITS : umber-
Size - t . x f t .
Stone size
PIPING : ze Type
Bldg . to Tank
Tank to Dist . Box - [7
Dist . Sox to Field/Pj'OtN n �+
Openings Sealed ? Yes No PartialLOCATION/SEPARATI
Foundation to Tank feet
Foundation to Absorption feet
Separation of Pits feet
onf orms as per Plot Plan es No
LOCATION OF SYSTEM ON PROPER
( circle one )
Front - Rear - Left Side Right Sid
Middle Front - Middle Rea
COMMENTS :
SYSTEM USE APPROVED : YES No
Arrived : Ir
Departed :
Building Inspector