SEP-0805-2023 SEPTIC DISPOSAL PERMIT Office Use Only
APPLICATION Permit#: ./tP- a 805- a�
Town ofQucensbun' D ��j �-y Permit Fee:$ 3S�00
�
r� Invoice#: 66369
742 Bay Road,Queensbury,NY 12804 DEC 7 }
P:518-761-8256 www. ueensbur .net Septic Variance? No
TOWN OF OUE NSBIJRY
BUILDING& CODESFlood Zone? No
I a _.."' _.._._,....�- _ Wetlands? No Reviewed B
Project Location: It CL.\s,`. Lk
Tax Map #: 9-7cl k _ l�s
RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms: X gallons per =total daily flow
per day bedroom Garbage Grinder Yes No
1980 or older 150 Installed? (choose one) ❑
1981-1991 130 2 r3o 2_6G, Spa or Hot Tub Yes No
1992-Present 110 Installed? (choose one) ❑
PARCEL INFORMATION:
Topography [ Flat Rolling ❑ Steep Slope % Slope
Soil Nature -/C Sand ❑ Loam ❑ Clay ❑ Other, explain:
Groundwater At what depth? A/A
Bedrock/Impervious material At what depth? y//t
Domestic Water Supply ❑ Municipal 1 Well ❑Lake
(if well or lake, water supply from any septic system absorption is
ft.) ?
Percolation Test A. n Rate: per minute per inch (test to be completed by a
r`� licensed engineer/architect)
PROPOSED SYSTEM INFORMATION: t tJEv3
Tank size ti ) gallons (min. size 1,000 ga Ions, gallons for ea
spa/hot t
System — Absorption field w/#2 stoneotal length (j ft.; Each Trench so ft.
� ; Size:many:
ee a e Pit w #3 stone How
p g / Y
Alternative System Bed or other type:
Holding Tank System Total required capacity? ; tank size •
# of tanks
Septic Application Revised July 2022
l
7
CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL
• Applicant: _ 1-
Name(s): Prr,.- pt\c /� '�t ,rIkc_
Mailing Address, C/S/Z: c C aol
Cell Phone: $c -222-q 76 Land Line: -
Email: i-,b 1,rke 6176 5-&--) wy,a,rf\
• Primary O pwner(s): II II
Name(s): .v�C) Prc_L JF " ke_ i va.` Oc_S kw\c-{"
Mailing Address, C/S/Z: 111I Li ,0 acrd*A t.c-e,
Cell Phone: S I ( `S ) Land Line:
Email: re.-vAvc\ deStcvv~lcmrs•-e.S ( MoCIL c-vm
❑ Check if all work will be performed by property owner only
• Contractor: II
Contact Name(s): ft-4re�dt �c,rkc
Contractor Trade: G e ���� l�n�. rc.Liy
Mailing Address, C/S/Z: 2 6 p G . ‘er) (7 5h`( N
Cell Phone: SrtQ- --222-q 7(,3 Land Line:
--
Email: pbc..- Q 77 re
**Workers' Comp documentation must be submitted with this application**
• Engineer(s):
Name(s): f(/A
Mailing Address, C/S/Z:
Cell Phone: Land Line:
Email:
PcJit4
Contact Person for Compliance in regards to this project:
glrerk(
Cell Phone: — 2)-7 -97 Land Line:
Email: ?1-,u,.r q- G S"O ihrni'• c v m
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: QA fie „ {��
SIGNATURE: � 2� L t DATE: 12 WO,/
Septic Application Revised July 2022
1 - . .5---. 6.11/1-- 1 2'--)11-72 r7--
` io gib
\5 c�` l (` < r PLOT .PLAN ' . r 95
SEPTIC SYSTEM . : .•� OF '• ENSBURY
SS` O -�%;; , is .. •1N13A DCODE
Notice: The following statement must be "stamped"'' on your plot
plan. This sheet of. paper may;.be usedfor 'purposes of
•' drawing`your plot plan After draw_ ing,::uch;plot plan, Ci°N7-'
5.
please read:the statement and sign it.:;',../•If you choose to : °-
Waluseother .paperfor your plot lan, the officewillstamp
those `plans for your signature. . ' .
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1.__�..__a,-.:_..._- s. -; .,,,,'• I have seen or otsetved' or believe I saw evidence of,
, ,'.« �: .x,. .. ;,;: all objects such ns hda dt,Arells,'trees,fences,etc.,
shown on this document. also:represent that I have
personally measur t .di nc set forth on the diagram."
w /6 /4004.5e SIGNATURE >:..: DATE