application flitSEPTIC DISPOSAL PERMIT APPLICATION Office Use Only
742 Bay Road,Queensbury,NY 12804
Town orc �d,n Permit#: z- -05 - ?Q.i P:518-761-8256 www.queensbury.net
Tax Map ID#: 11 Permit Fee: $ ; Invoice#: rill
Project Location: .L+4---) Fi-f-ii\ 5i-g, Septic Variance? Yes No
Primary Owner(s) Eel c - L 01 y r DvN
Mailing Address *1-)---) Fc� k St.
Phone & Email .5«_4 -3_ 1
Installer/Builder �,B �ff*t C
Mailing Address ; L r • •
Phone & Email l
Engineer p��t\ .,t1N,•
IA Ion E. tU• - ' l
Mailing Address -----"-�-"- -1
Phone & Email `,,\ \ AUG 23 2019
is i
Contact Person for Building&Code Compliance: „V v- Phgrte:' y---) (,1-L�6�
roan';) '
RESIDENCE INFORMATION: PC'l`t';
Year Built Gallons #of bedrooms X gallons per =total daily flow
per day bedroom Garbage Grinder Yes N
1980 or older 150 Installed? (circle one)
1981-1991 130 Spa or Hot Tub Yes No
Installed? (circle one)
1992-Present 110 / 1 1 O 2'1 U
PARCEL INFORMATION:
Topography at Rolling Steep Slope %Slope
Soil Nature Sand Loam Clay Other
Groundwater At w at depth?
Bedrock/Impervious material At hat depth?
Domestic Water Supply unicipal _Well (if well,water supply from any septic system absorption is_ft.)
Percolation Test Rate: per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED,,��Y.STEM FOR NEW CONSTRUCTION:
Tank sizl?'/'"''` 1 OM 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 IS () ft.; Each Trench 5 C 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 &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.
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 b r on behalf of an applicant, shall be void. I
have read the regulations and agree to abide by these and all require nts of the Town of Queensbury Sanitary Sewage
Disposal Ordinance.
PRINT NAME: :: 1
: ---1-3--- 1 /-
SIGNATURE: : fg
Town of Queensbury Building&Code forceme t Revised March 2018