SEP-0165-2023 SEPTIC DISPOSAL PERMIT Office Use Only
APPLICATION Permit#
7rnmufC7u�rnsbttry �� E R W E
Permit Fee:$
742 Bay Road,Queensbury,NY 12804
APR 17 2023 Invoice#:01
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P:518-761-8256 www.gueensbury.net _ Septic Varianc B
TOWN OF QUFBNSISURY
BUILDING& CODES Flood Zone? No
,u Wetlands? No Reviewed By:
Project Location: q 71 I�,�Q a k04 d
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 3 I 11D 3 3 p Installed? (choose one) ❑
1981-1991 130 Spa or Hot Tub Yes No
1992-Present 110 Installed? (choose one) ❑ [�
PARCEL INFORMATION: or
Topography Flat Rolling ❑ Steep Slope % Slope
Soil Nature and ❑ Loam ❑ Clay ❑ Other,explain:
Groundwater At what depth?
Bedrock/Impervious material At what depth?
Domestic Water Supply ❑ Municipal ❑ 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 l000 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 I %o ft.; Each Trench Wp 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 July 2022
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant,•
Name(s): r85 S�pf-( f
Mailing Address, C/S/Z: 7- -1� q^
Cell Phone: S't%- 7 V 6-DgS4 Land Line: 5)4b-I t-$/t'7
Email: pSTy 1gD31 �a,lt,rc-^,
• Primary Owner(s):
Name(s): Vi„cen t Spero
Mailing Address, C/S/Z: 9-72 AAle Roo d
Cell Phone: S't%- Vb0-712`( Land Line:
Email:
❑ Check if all work will be performed by property owner only
• Contractor:
Contact Name(s):
Contractor Trade:
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:
Cell Phone: S1--146 01r6 Land Line: f1%- 7gr1- %/' /
Email: iPS ;ales 9 ;
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: ERIC
SIGNATURE: DATE: 'Z .
Septic Application Revised July 2022
JOB �1 1�, \'t 1EIP, QUz
SHEET NO. OF
WATER • WASTEWATER • STORMWATER CALCL. AT JD BY DATE
SOLUTIONS SCALE Leas s \& o �
�� ! r 290.10-1-32 —�--
SEP-0165-2023
Spero, Vincent - --
APRIR 7 023 975 Ridge Rd
Residential Septic Alteration
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