SEP-0598-2023 SEPTIC DISPOSAL PERMIT Office Use Only
APPLICATION Permit#: r��J�� - ZOZ3
Town ofQueensbury Permit Fee:$ 4
Invoice#:
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.aueensbury.net Septic Variance? Y O
Flood Zone? Y
Wetlands? Y Reviewed By
-Project Location:
Tax Map #: �J P
RESIDENCE INFORMATION: 11 S J`
fl U EP Z® 2023 � f
Year Built Gallons #of bedrooms: X gallons per =total daily low
per day bedroom r0I,1'i! "` '�``
g rfjage IV H I � Yes No
1980 or older 150 pC� =Insfalled3z<,(eh.00 eone) ❑
1981-1991 130 Spa or Hot T'ub Yes No
1992-Present 110 Installed? (choose one) ❑
PARCEL INFORMATION:
Topography. ❑ Flat Rolling ❑ Steep Slope % Slope
Soil Nature Sand . ❑ Loam ❑ Clay ❑Other, explain:
Groundwater At what depth? >D o
Bedrock/Impervious material At what depth? (DU to "-70
Domestic Water Supply �]C 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 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 - a ft.
Seepage Pit w/#3 stone How many: ; Size:
Alternative System Bed or other t pe:
Holding Tank System. Total required capacity? ; tank size ;
# of tanks
Septic Application Revised July 2022
w
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): J� cc.Ljt!t '
Mailing Address, C/S/Z: /0 Gv^6no- -D V
Cell Phone: $/8 Land Line: Nl A
Email: vc.CC GVl--L
• Primary Owner(s):
Name(s): '�C a& 1 y-d)ef �P,2_,e J
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email:
0 Check if all-work will be performed by property owner only
• Contractor:
ContactName(s): MiJwl
Contractor Trade: o Lo
Mailing Address, C/S/Z: /o
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 Pers n for Compliance in regards to this project: cAaCI('
Cell Phone: �1Q, 7 ��o—� c�� Land Line:. ,�J
Email: E
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: Vim'- UCL JQ A i
SIGNATURE: DATE: L
Septic Application Revised July 2022
X
r INC
� s z
1
r
f
v^®PY tA
UN
o�
L
{
-'O1VIN OF 9U
BU1LDINU { {)
RevieweO
Date". --- TavoyS
295.15-1-46 SEP-0598-2023 '���� s��1 �+ -�o Nfvlo_t
Shaffer, Martin
18 Moorwood Dr � 0 Z d3S
Residential Septic Alteration u —
/AA Mil 3 7
r
r {�
IF
�� 3 tm �t.cNt. "6X� rY 6 Y� 1 Cyry
a¢,�i '1'SI 'L '`f'," �afl` t'S"1Tt'". {Yz„aC
J I