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Application Office Use Only SEPTIC DISPOSAL PERMIT APPLICATION Permit#: p- 04\n-- 0 e) Permit Fee:$ 1p - : Invoice#: 1$2:. Town of Septic Variance? Yes No 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.queensbury.net Tax Map ID#: 240.06-1-32 Project Location: 2464 Ridge Rd • Applicant: Name(s): Garner Unlimited Mailing Address, C/S/Z: PO Box 298 Cleverdale, NY 12820 Cell Phone: ( 518-656-5053 ) Land Line: ( ) DIE © E O V Email: Click or tap here to enter text. JUL 222019 • Primary Owner(s): Name(s): Garner Unlimited TOWN OF QUEENSBURY BUILDING & CODES Mailing Address, C/S/Z: Cell Phone: ( ) Land Line: ( ) Email: Click or tap here to enter text. ❑ Check if all work will be performed by homeowner only • Contractor: Workers' Comp documentation must be submitted with this application Contact Name(s): Chris Crandell Contractor Trade: Click or tap here to enter text. Mailing Address, C/S/Z: Click or tap here to enter text. Cell Phone: (518-470-4694 ) Land Line: ( ) Email: Click or tap here to enter text. • Engineer(s): Name(s): D.L. Dickinson Associates Mailing Address, C/S/Z: PO Box 388,Lake George,NY 12845 Cell Phone: ( ) Land Line: ( 518-668-4676 ) Email: dldickinson78@gmail.com Contact Person for Building&Code Compliance: Mike Chrys Cell Phone: (518-656-5053 ) Land Line: ( ) Email: Click or tap here to enter text. Septic Application RESIDENCE INFORMATION: Year Built Gallons #of bedrooms: X gallons per =total daily flow per day bedroom 1980 or older 150 Click or tap here Click or tap Click or tap here to to enter text. here to enter enter text. text. Garbage Grinder Yes No 1981-1991 130 Click or tap here Click or tap Click or tap here to Installed? (check one) El to enter text. here to enter enter text. text. 1992-Present 110 5 110 550 Spa or Hot Tub Yes No Installed? (check one) ❑ El PARCEL INFORMATION: Topography ►5 Flat Rolling ❑ Steep Slope %Slope Soil Nature El Sand ►I Loam ® Clay ❑ Other(explain: Groundwater At what depth? None Bedrock/Impervious material At what depth? None Domestic Water Supply ❑ Municipal ® Well (if well,water supply from any septic system absorption is_100_ft.) Percolation Test Rate:_22_per minute per inch (test to be completed by licensed engineer/architect) PROPOSED SYSTEM FOR NEW CONSTRUCTION: Tank size _1500_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 ft.; Each Trench ft. Seepage Pit with#3 stone How many: ;Size: Alternative System Bed or other type:_bed 11.2'x 52' 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: Mike Chrys SIGNATURE: Click or tap here to enter text. DATE: 7-22- Septic Application Revised ,n,c