2024-0175 SEPTIC DISPOSAL PERMIT Office Use Only
APPLICATION Permit#: 20 6 '}-5
Town ofQuc Snc bury Permit Fee: _ ic)
Invoice#: %.
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net Septic Varianc• ' -No
Flood Zone? No
Wetlands? No Reviewed By: ��
11A9
Project Location: ISOS R'ic1 e R
Tax Map #: 116 a31--71 ,
RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms: X gallons per =total daily flow
per day _ bedroom Garbage Grinder Yes No
1980 or older 150 2 30o Installed? (choose one) ❑
1981-1991 130 Spa or Hot Tub Yes No
1992-Present 110 Installed? (choose one) El [Z
PARCEL INFORMATION:
Topography (]Slat Rolling ❑ Steep Slope % Slope
Soil Nature N4and ❑ Loam ❑ Clay ❑ Other, explain:
Groundwater At what depth? Or
Bedrock/Impervious material At what depth?
•
Domestic Water Supply ❑ Municipal Nell ❑Lac Ine
(if well or lake, water supply from f '� septic system abso i n is
ft.) / APR 11 2024
4
Percolation Test Rate: per minute per inch ( esctohbWco . pleted_by a
E�U[LdfN��ERJSg�PY
licensed engineer/architect) G&� cCASF�
PROPOSED SYSTEM INFORMATION:
Tank size 12.50.gallons (min. size_1,00.0_gallons,-add_250_gallons for each garbage cylinder or
spa/hot tub -kxviiv ep.le.C,r;;rt n.
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
fkwykr.,
Septic Application Revised July 2022
l
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): Ya S 4erk( O- LLC
Mailing Address, C/S/Z: 2 Lower 1 rie..Sf Ives'
Cell Phone: 51$--7 y 6-c'53-6 Land Line:. S<g- WIT- /j'9
Email: eSb:lpleyna 65*SPp Le •CcP.-
• Primary Owner(s):
Name(s): 54efl;q So-j�ati5 Kt
Mailing Address, C/S/Z: iSo$ tctie RO 061'
Cell Phone: 519-5®2- eio3o Land Line:
Email: cI fivK
Check if all work will be performed by property owner only
• Contractor:
Contact Name(s): ..r Rtc 511:p ley
Contractor Trade: ph.n,b``h9 i- Cep i.'i
Mailing Address, C/S/Z: Z Lva.ver lgpcir►rnh 5 fi OR k
Cell Phone: Se'$- 1 tit 6-o 5i Land Line: f°I - -71V- I'9 S'
Email: esl. le y9 i`bsSepR:C.rog.-
**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: ERic I SI,i Q hie 7
Cell Phone: '� ��i 1 Ogce Land Line: 5!I79'1- g mr t y
Email: esLi:plpy 9ib0Sepi.r• Cow.,
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: Gitrr 3. 5It p/f y
SIGNATURE: C , g-144,,e07 _ DATE: i'I/42.y
Septic Application Revised July 2022
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BGNIN DEPARTETBased on our I(mitetlexaminaltion_omplian e
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