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2024-0502 2 rc E I v 2 -z Office Use Only SEPTIC DISPOSAL A 2 Z c,j— 0ES Ca_ Permit#: SEP 18 2024 Permit Fee: Town of Qucensbury TOWN OF QUEENSBURY Invoice#: 742 Bay Road,Queensbury,NY 12804 BUILDING&CODES P:518-761-8256 www.queensbury.net �P Flood Zone? TYPE: Project Location: ko3 Sees U� Q%g�S6t' � 1 t Wetlands? Y ►/ Reviewed By: Tax Map #: 22 s kr( - 1—LtTT STRUCTURE INFORMATION Garbage Grinder Yes No Year Built Gallons #of X gallons per =total daily flow Installed? Per day Bedrooms Bedroom 1980 or 150 Spa or Hot Tub older Installed? 1981-1992 130 1992-Present 110 .;, PARCEL INFORMATION / TOPOGRAPHY Flat Rolling Steep Slope N % Slope SOIL NATURE Sand /'� Loam Clay Other, explain: GROUNDWATER At what depth: BEDROCK/IMPERVIOUS MATERIAL At what depth: DOMESTIC WATER SUPPLY Municipal Well /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 z-56- gallons (min. size 1,000 gallons, add 250 gallons for each garbage cylinder or spa/hot tub ,;z4E-04 i1 --rc•p\k: *J PfSYSTEM Absorption field w/#2 stone Total length ft. EafRETAtota4 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: Septic Alteration Application Revised May 2024 CONTACT INFORMATI ON: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL • Applicant: Name(s): 6czaft 5ti-Mailing Address, C/S/Z: I-f -lit\onai\- kb Cell Phone: 5 6 - 3 61 r- ) 2g ri Land Line: OM Email: 5c_oft kjuJ(o' c_11001. v\)L CO+'A • Primary Owner(s): Name(s): 'tAcCo\l; ,+e( Mailing Address, C/S/Z: pO ,b?( 2.010 / CJeVelroldle , i"W 12$Z0 Cell Phone: 51 S Z 60 —6ci Z© Land Line: Email: inc c eLkAS- f 5 t gitvlai , G© iflel ❑Check if all work will be performed by property owner only • Contractor: - Contact Name(s): f 15 v.9 D�( 4-1v\ -4- 6r)A. ��lb ^�i ✓� /�f Contractor Trade: U _ MailingAddress, C/S/Z: to Z- 5 .4- �v , F r"+ -AA. wy 17,021 Cell Phone: T( Es— `ict3 Land Line: 5 {g-79Z_"' c 2. 4, Email: **Workers' Comp documentation must be submitted with this application** • Engineer(s): Name(s): Mailing Address, C/ /Z: I Cell Phone: : Land Line: Email: Contact Person for any questions regarding this project: AvO,ke n(ok— Cell Phone: Land Line: 1 a� 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: 6 co K,; lR 5 (� - SIGNATURE: DATE: 9/f B/z if' Septic Alteration Application Revised May 2024 F- P Fi Resi n i I Pr c s OS-072 Md I' er 5U�{SSgNS F RW7 APPR04AL OJ-13-GS 0306St00603 YCCO{115 R WW S15T O4-27-OS.UN IM E'I o' r. m m m o .. i✓ a GT[ w a T': y� P I^ t $r r A � C: �. - 'ro CD l 1 c�a C a 0 m t' pAt10 1 rn D A 5) 1 g ' 1 IR / C 2 l F Np ev r rAll ® Z Iv Z CL G) -n r c' � , N o C nn`r' ooii' ii m ? p5 I F 75� $ c ionnv v pz~�i�i ®o Q oo 8 AyC K S yl O � Enp ;�AOm �® ON Z ° s a � R. o zb � �'o -. o in io o± �co aF' ' �o a'm` '3''7' ^' s 'o •o m D. •o,:w 5- 1 $ •p"?�o >R. Sc m3.y7am ac't y uu P- of a ;z s ag SzN $_ ri's S c cY fs p �gyzr4 �enogm... o cp 4. =g� N gn3o $;m pm O i gyp? m �i aIZIp�S_ O 3 JJ y= m o � OOa`Y E <Q D z c v o� goS�p ivy m - `AG VHF �� 4 gaw > 0 o>Fg �i� a3 v �S a t Try p nm ITl M D ; n i o z� v� a u~mi S � ��� •+ � � •+.� m a i $ - y> m �D w o sso zwrm .Q 19 %4 zv m v bo z� � 8 c23Zgvoc� o� a m m� a p o o D9 c Z< a cw A 4 m O `yfy � s g� aFi W C C