application SEPTIC DISPOSAL PERMIT APPLICATION office Use Only
742 Bay Road,Queensbury,NY 12804 �����((��
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Permit#: G�t'r ��2-' 220\21-
P:
518-761-8256 www.gueensbury.net
Tax Map ID#: ZZIa.15- 1 - 1 Permit Fee:$ �O J Invoice#: Z-T bL
Project Location: Septic Variance?? Yes No
Primary Owner(s) J %*LALF—
Mailing Address L�4tA*- LAVLE t�1.- 1
Phone & Email
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Mailing Address DEC 0 5 2017
Phone & Email
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Engineer t►1I-,-? O•{ - Et4 %
Mailing Address -4 ����� �-f�'T - �-�
Phone & Email �1$Z6i_(--Mt'7 C-Cwy"
Contact Person for Building&Code Compliance:'t*-)w_%►,xt-_5 T*^Ac-Eti-'Rch' Phone: SIPS '5,74--A-H e)S
RESIDENCE INFORMATION:
Year Built #of bedrooms X gallons per bedroom =total daily flow Garbage Grinder Yes o
1980 or older Installed? (circle one)
1981-1991 Spa or Hot Tub Yes
Installed? (circle one)
1992-Present 3 1 1 O 3
PARCEL INFORMATION:
Topography Flat Rolling Steep Slope %Slope
Soil Nature �_Sand x Loam Clay Other
Groundwater At what depth? 40 ' ( ►s-r�►�yc.
Bedrock/Impervious material At what depth? > '7Z"
Domestic Water Supply —Municipal X Well(if well,water supply from any septic system absorption is_ft.)
Percolation Test Rate:J_per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size I k�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: `TM—%W= U - eu:>L -eT/4L
Holding Tank System Total required capacity? ;tank size T;#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 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 Ordinnanncce.�
PRINT NAME:__I-- � � DATE:
SIGNATURE: J, tyyn DATE: 1Z`moi--L7
Town of Queensbury Building&Code Enforcement Revised February 2017