application/f9-2-2
TOWN OF QUEENSBURY
APPLICATION FOR SEPTIC DISPOSAL PERMIT Permit #93 -
Fee Paidth Sts
RECEIVED
Date:20-D Reviewed By
APR 77 1993
LOCATION OF PROPERTY FOR INSTALLATION:Canin BERRY
Gerertsinane:SIO paues oll/e >&CODE DEPT
Owner's Mailing Address:RD Boy 239 Crna Le Bescy De
Installer's Name:Pew riers LE btn Phone #:Z22-22s 7
Number of bedrooms (if a:2
Total daily flow (residential-compute @ 150 gal.per bedroom):_YSO
Topography-Circle One:Rolling Steep Slope —%of Slope
Soil Nature-Circle One:and Loam Clay Other /Depth:
Ground Water-At What Depth?Feet
Bedrock or Impervious Material-At What Depth?Feet
Percolation Test-Circle One:(GeRequiredYRequired/Rate Min.Per Inch
Domestic Water Supply-Circle On unici Well Other
If domestic water supply is a we =
Separation:Water supply from any septic absorption feetbist’
PROPOSED SYSTEM:Septic Tank /ODD gal.(Minimum size:1,000 gal.)
Tile Field:Each Trench feet//Total System Length feet
Seepage Pit(s):Number of _2—/Size each:P ft.x PR ft.
Size of Stone to be used:#3 /Depth or Thickness _2-—_feet
Jo onneienieee
HOLDING TANK SYSTEM IF REQUIRED
No.of Tanks Size\of Each Gal.
Alarm system and associated electrical work to be inspected by a certifiedEeFOIIR
T have read the regulation on the reverse side of this sheet and agree to abide
by these and all requirements of the Town of Queensbury Sanitary Sewage Disposal
Ordinance.
SIGNATURE OF RESPONSIBLE PERSON:DATE:%—20-9