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SEPTIC DISPOSAL PERM ITAPPLICATION Office Use Only 742 Bay Road,Queensbury,NY 12864 rownotcZansnuzy p:518-761-8256 www.gueensbury.net Permit#: f��9© 2QLS Tax Map ID#: 296.19-1-12 Permit Fee:$ `�-S ; Invoice#: OS Project Location: 33 COUNTRY CLUB ROAD Septic Variance? Yes No Primary Owner(s) MICKEY HAYES,HAYES&HAYES LLC Mailing Address 297 SARATOGA AVE,SOUTH GLENS FALLS,NY 12803 Phone & Email 518-792-9142 Installer/Builder SAME AS OWNER I rill LE (LI" 0 V LIB F*) Mailing Address �U� r-- -� -- IN I Phone & Email JUN 22 2018 I IJ I Engineer HUTCHINS ENGINEERING-TOM CENTER 11JWIV \✓F OY.V EE YV\.rva\M. Mailing Address 169 HAVILAND ROAD,QUEENSBURY,NY 12804 BUILDING&CODE y� Phone & Email 518-796-2515 TCENTER36@YAHOO.COM Contact Person for Building&Code Compliance: MICKEY HAYES Phone: 518-792-9142 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 No 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" Bedrock/Impervious material At what depth? NONE Domestic Water Supply ,/ Municipal _Well (if well,water supply from any septic system absorption is_ft.) Percolation Test Rate: 7 per minute per inch (test to be completed by licensed engineer/architect) PROPOSED SYSTEM FOR NEW CONSTRUCTION: Tank size 1 1000 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: 15 FT X 40 FT=600 SF 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 factor 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: MICKEYHAYES DATE: 6/21/18 SIGNATURE: Town of Queensbury Building&Code Enforcement Revised February 2017