application SEPTIC DISPOSAL PERMIT APPLICATION Office Use Only
742 Bay Road,Queensbury,NY 12804
Town of Queens P:518-761-8256 www.queensbury.net Permit#: CS' e` " o �2-9- ' 2tt�
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Tax Map ID#: 266.1-1-14.1 Permit Fee: $ 1S ; Invoice#: 0c12Z
Project Location: 17 OAK VALLEY WAY Septic Variance? Yes No
Primary Owner(s) KURT&LYNN JAEGER
MailingAddress 5ECEIIVIE \-11
17 OAK VALLEY WAY .,..,..�
Phone & Email I SEp 2 g 201
Installer/Builder ELLSWORTH&SON Ui
Mailing Address 10302 NYS RT 149,FORT ANN NY 12827 TOWN OF GtU��NSB
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Phone & Email 518-361-1993BUILDING& roDES
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Engineer TOM CENTER HUTCHINS ENGINEERING
Mailing Address 169 HAVILAND RD
Phone & Email 518-796-2515 TCENTER36@YAHOO.COM
Contact Person for Building&Code Compliance: TOM CENTER Phone: 518-796-2515
RESIDENCE INFORMATION:
Year Built #of bedrooms X gallons per bedroom =total daily flow Garbage Grinder Yes No
1980 or older Installed? (circle one)
1981-1991 Spa or Hot Tub Yes 0
Installed? (circle one)
1992-Present 3 110 330
PARCEL INFORMATION:
Topography ✓ Flat Rolling Steep Slope %Slope
Soil Nature Sand / Loam Clay Other
Groundwater At what depth? 24 INCHES
Bedrock/Impervious material At what depth? NA
Domestic Water Supply _Municipal /Well (if well,water supply from any septic system absorption is 150 ft.)
Percolation Test Rate: 8 per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size 1250 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 360 ft.; Each Trench 60 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 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: TOM CENTER HUTCHINS ENGINEERING DATE: 8-29-18
SIGNATURE: 7
Town of Queensbury Building&Code Enforcement Revised February 2017