2024-0310 Office Use Only
SEPTIC DISPOSAL APPLICAT)QN Permit#: 202.11--03IC
ele D EPermit Fee:$ E),)�
Town of Qucensbury
742 Bay Road,Queensbury,NY 12804 JUN 27 2024 Invoice#:
P:518-761-8256 www.queensburv.net TOWN OF QUEENSBURY Flood Zone? Y TYPE:
ir-
UILDING&CODES
Project Location: 3 air Lk, Wetlands? Y
Reviewed By:
Tax Map #: , , — I-53
STRUCTURE INFORMATION Garbage Grinder Yes No
Year Built Gallons #of X gallons per =total daily flow Installed? El ❑
Per day Bedrooms Bedroom
1980 or 150 Spa or Hot Tub
older - Installed? ❑
El
1981-1992 130
1992-Present 110 5 55o
PARCEL INFORMATION
TOPOGRAPHY Jlat Rolling n Stee Slope % Slope
SOIL NATURE ./Sand Loam Clay Other, explain:
GROUNDWATER At what depth: .,
BEDROCK/IMPERVIOUS MATERIAL At what depth:
DOMESTIC WATER SUPPLY FAVlunicipal P Well n Lake (if well or lake, water
supply from any septic system absorption is feet)
PERCOLATION TEST Rate: per minute per inch (test to be completed
by a licensed engineer/architect)
PROPOSED SYSTEM INFORMATION
TANK SIZE 1.10e gallons (min. size 1,000 gallons, add 250 gallons for each garbage
_ cylinder or spa/hot tub E 6+' T4
- SYSTEM Absorption field w/#2 stone Total length VI, ft. Each trench ,Co ft.
Seepage pit w/#3 stone How many: ; Size:
Alternate system Bed or other type:
Holding tank system Total required capacity: ; tank size:
; # of tanks:
Septic Alteration Application Revised May 2024
CONTACT INFORMATI ON: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): Tfc S� �,C Ot :n ZLc
Mailing Address, C/S/Z: Z Lc;arg, 1A4V7PH 5t Cf2e)
Cell Phone: Cht- c.f Land Line: Si 791 V/! 9
Email: €5 A:hip 1'L55'ep/.`c' , (01--N
• Primary Owner(s): 1
Name(s): Mq f--t /41% rO
Mailing Address, C/S/Z: 361 Set r9 In ;ve
Cell Phone: Ss ci,a S2. '1- 63( 2 Land Line:
Email:
❑Check if all work will be performed by property owner only
• Contractor:
Contact Name(s): 4.195 Cep1,c OfLiIY1 LLB
Contractor Trade: pL„sJ Sep k
Mailing Address, C/S/Z: Leteiav, 'I ' rre, 51- OR V
Cell Phone: Sam- "74-0<g '6 Land Line: q,c- 7n—V9 9
Email: 6,4:a4y�,.'bsS��� < Co
**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 any questions regarding this project:
Cell Phone: Land Line:
Email:
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: EA, C Y51'ple y
SIGNATURE: ,` r DATE: /7:7 tz 9
Septic Alteration Application Revised May 2024
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2024-0310
Miron, Matt hew
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