2015-471 � Cep �
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Town of Queensbury■ Building&Codes Enforcement Office■742 Bay Road■ ury,
DEEP HOLE/PERC TEST w U 2015
Request for Town Engineer Review TOWN OF QU>WENSBURY
� y ►rn ! t— BUItplN1 &CODES
Property
ProP rty Owner: Phone: -7/ 1
71
Property Owner's
Address: " l -'TQ —
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Location of Test: � t2ntQ0 Tax I D#: a4M.
`Applicant's Engineer: �i(,�� ��.C� �Qw t Phone: S — [11V5
Applicant's Agent: r=N b - .• Phone: Cl{J—1 4:5105
Additional Notes:
1. Reason for Request? ❑ New Septic System Replacement Septic System Failed Septic System
ElSubdivision D Site Plan Review
2.Are Wetlands present? YES NO F—] UNKNOWN
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*Note: _Applicant is required to engage an engineer for design and testing of the system. The Tow p
Engineer's responsibility is to witness system testing only. CV
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PLOT PLAN: Plot plan, to scale, to be submitted with application D
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FEE SCHEDULE: ( 0
a. $200 Flat Fee Date Paid: l a f CL
Check No.: ~ p (U
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b. OR Fee to be determined during To Be Determined: C M =
Site Plan 1 Subdivision review process N CL
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SIGNATURE: �O D
In carrying out the provisions of Article IV, the Local Board of Health or the enforcement officer m;
engage the services of a qualified professional consultant for expert review and recommendation arising
from the carrying out of the provisions of Art. IV, including but not limited to the review of plans,
specifications and reports, attendance at inspections, dye tests, deep hole test pits, septic related deep
hole and percolation tests, system installations, and any other aspect of any matter contained in this Art.
IV, and any costs incurred in such review shall be paid to the Town by the owner of the property before
any approval can be granted under this Art. IV shall become effective within 30 days of presentment of an
invoice for same, whichever is sooner. Such costs shall not exceed $1,500 without prior written notice to
the party to be charged with same.
My signature below indicates I have thoroughly read and understand the instructions, agree to the
submission requirements and have completed the application. I also fully understand that additional
engineering fees may be necessary per Town of Queensbury Local Law 136-14D.
SIGNATURE OF APPLICANT: Date:
SIGNATURE OF AGENT: Date:
Original (S&C File) Canary (Planning) Pink(Applicant) Gold (Town Clerk)
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Map is for GENERAL REFERENCE ONLY. /' L C-'I QA
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