application SEPTIC DISPOSAL PERMIT APPLICATION Office Use Only
Town or Permit#: !— ��� � PI
° Permit Fee: $ .5 ; Invoice#: 1l�zo
742 Bay Road,Queensbury,NY 12804 Septic Variance? '/ Yes No
P: 518-761-8256 www.queensbury.net
• Primary Owner(s): Project Location: (9 f 1i-ZQ E I-D COPI D
Name(s): CtFUD'R elms-FEN Tax Map ID #: 2f 1 1 q- - —
Mailing Address, C/S/Z: (Pl 4 GEI?I LO
Cell Ph.: ( 5( ) 222- (eS1R Land Line: (
Email: C crrs t- An 212 Cam' @ rnaAt, CQV'V
• Installer/Builder:Name(s): 160 \ ,/EG
Mailing Address, C/S/Z: JUN 05 2019
Cell Ph.: ( ) Land Line: (
Email: pF QUEENSBURY
• Endineer(s): TOBUILDING&CODES
Name(s): NS-1 t-, LI AV-C-01TE 01312E
Mailing Address, C/S/Z: 60( P\'E CIL.ENS 4l O
Cell Ph.: ( ) Land Line: (6t F, ) 141 O2(P S
Email: e p hit e C(,tr. I r, CG'YYl
Contact Person for Building&Code Compliance: Cell Ph.: (
RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms X gallons per =total daily flow
per day bedroom
1980 or older 150 _ _ Garbage grinder installed? ❑ yes 1 1 no
1981-1991 130 _ _ Spa or hot tub installed? ❑ yes XI no
1992-Present 110 — 3 _ ('I
-
PARCEL INFORMATION:
Topography Flat Rolling XSteep Slope %Slope
Soil Nature ESand ❑Loam ❑Clay lXOther Click or tap here to enter text.
Groundwater At what depth?Click or tap here to enter text.
Bedrock/Impervious material At what depth? Click or tap here to enter text.
Domestic Water Supply 01Municipal Well(if well,water supply from any septic system absorption is ft.) LAKE
Percolation Test Rate:_per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size 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:
�( Holding Tank System Total required capacity? 3U(C ;tank size It CO;#of tanks 3
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 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.
PRINTNAME:C- a-Ud( K
SIGNATURE: DATE: 6/S-/2()/9
Principle Structure Appli Revised January 2019