2024-0434 "s
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.,� Office Use Only
„i SEPTIC DISPOSAL A' A 1 i 1.6�, Permit#: 20 —
AUG 19 2O2'g Permit Fee:$
Town of Qucensbury
i:i31yC'f`�.4.�t.��.ip�. t \
742 Bay Road,Queensbury,NY 12804 . ci t,,Y Invoice#
TOWN OF
P:518-761-8256 www.queensbury.net BUILDING 8,COl mac'
gel
Flood Zone?- Y PE: ;. N
Project Location: 32 y Vey, A i gel d Wetlands? Y
Reviewed By:
Tax Map #: 2 V 9. 9 - !- ld
STRUCTURE INFORMATION Garbage Grinder Yes No
Year Built Gallons #of X gallons per =total daily flow Installed?
0 4
Per day Bedrooms Bedroom
1980 or 150 3 Y5,D
Spa or Hot Tub
older Installed?
1981-1992 130
1992-Present 110
PARCEL INFORMATION
TOPOGRAPHY lat Rollin n Stee Slope % Slope
SOIL NATURE Sand Loam Clay ther, explain:
5q..4 t Decks
GROUNDWATER At what depth: win
BEDROCK/IMPERVIOUS MATERIAL At what depth: N/#
DOMESTIC WATER SUPPLY Municipal ell [1 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 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 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:
v 1NSfQl...Q 69 PI lkl�nh )Kf g✓ k.fCAIPh
P41 10 4t61k Oa if Of.ve tiitay
Septic Alteration Application Revised May 2024
CONTACT INFORMATI ON: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant:
Name(s): 165 SerPc Ofq ►-, 11
Mailing Address, C/S/Z: 2 Lower Lowe.., 5 I Qi.eP,. p c .-8-r , yv f' I Zi0 V
Cell Phone: cis- 7 y(o• o4,5-4 Land Line: $'/t - 79$-.3/f Y
Email: el4:10 ey a7 i Lcsee.? .Cow..
• Primary Owner(s): nn
Name(s): 5&$qN,,,P /Vwr f i o .
MailingAddress, C/S/Z: (Pi 5` Anil CZ Ivo,rti e•Ieii VT D5C43
Cell Phone: ' oZ.' 27Z- C II 7 Land Line:
Email:
❑Check if all work will be performed by property owner only
• Contractor:
Contact Name(s): ref SPp/•c ,.f A.4 ,.,
Z4ontractor Trade: 2 Low.i tirtwe. S'?, 0vov,.s,6c.,,7, Ile• Y /ZQo y
ailing Address, C/S/Z: Pi`o,4r1 t Zpf•c
Cell Phone: Sid-7Y6 og4 /, Land Line: ,-If - w$'-¢/¢ y
Email: 54Pler £ s hsSepL.'. Co•4-.
**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: Erg c. T. 5 h.?le
Cell Phone: 'S'ij- "7(b`df4 S 6 Land Line: Si$• 7Q$ - 1/9
Email: t s4,Q/er P. nifty/.('. Co .-
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: Gr•c T. 54.' 6
SIGNATURE: vim^ U ?�' DATE: $/3/2y
Septic Alteration Application Revised May 2024
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