application Office Use Only
Permit#: 06-4Z-LO 1�
SEPTIC DISPOSAL PERMIT APPLICATION Permit Fee: $ ; invoice#: 1 to tI
Town ofCZiccn ury Septic Variance? Yes No
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net
Tax Map ID#: ° �'3 St ` d /%(J
Project Location: II JDkMO4 4e. �/fir 09 (//
• Applicant:
Name(s): C.S G P d f Ai(JP
Mailing Address, C/S/Z:
Cell Phone: _( S(2 ) 36.9 -{ Land Line: _(
Email: j 0 10.. 0,10C C-0;11
• Primary Owner(s):
Name(s): ell0/96&' domtf �/
Mailing Address, C/S/Z: P® &9( '7� 7 Say 1ya Sptm 1 s 4)
Cell Phone: _(_ ) Land Line: _( )
Email:
p[Lcpc,27' t)wA/62
❑ Check if all work will be performed by h der only
• Contractor: Workers' Comp documentation must be submitted with this application
Contact Name(s):
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: _(
Email:
• Engineer(s):
Name(s):
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: _(
Email:
Contact Person for Building & Code Compliance: IV 3C
ti
Cell Phone: ( 6i8 ) Land Line: _(
Email:
Septic Application Revised February 2019
RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms: X gallons per =total daily flow
per day bedroom Garbage Grinder Yes o
1980 or older 150 Installed? (circle one)
1981-1991 130 Spa or Hot Tub Yes
!� Installed? (circle one)
1992-Present 110
PARCEL INFORMATION:
Topography .Flat Rolling Steep Slope %Slope
Soil Nature Sand Loam _Clay Other(explain:
Groundwater At what depth?
Bedrock/Impervious material At what depth?
Domestic Water Supply Municipal _Well (if well,water supply from any septic system absorption is ft.)
Percolation Test Rate:/t)ff per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size !r 000 gallons(min. size 1,000 gallons, add 250 gallons for each garbage cylinder or spa/hot tub
System Absorption field with#2 stone Total length_lee) ft.; Each Trench ft.
Seepage Pit with#3 stone How many: ; Size:
Alternative System Bed or other type:
Holding Tank System Total required capacity? ; tank size ;#of tanks
NOTES: 1. Alarm system and associated electrical work must be inspected by a Town approved electrical inspection
agency; 2. We will no longer allow systems to be covered until such time as an as-built plan is received and
approved. The installed system must match the septic layout on file—no exceptions. 3. As-built drawings must be
submitted prior to the inspection, if there has been a change to the submitted plans.
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: VP-1 DATE: 01.0(g--/I
SIGNATURE: ADATE: PLC/
S ntir Annliratinn Revised February 2019