application çJ ) SEPTIC DISPOSAL PERMIT APPLICATION Office Use Only
------;-2 742 Bay Road,Queensbury,NY 12804 I g
Town ofQccnsbmp Permit#: 7
P:518-761-8256 ww .cmeensb sry.ne`
� 7
Tax Map ID##: - � L . ) — /'*" �. Permit Fee:$i g Invoice#: OS
Project Location: - "- Per -ho -6.7 Septic Variance? Yes No
Primary Owner(s)» , fin
Mailing Address ' d- s f ''erF /sin 1 .
Phone &Email '� v,../D e 1 11,(1 e, 47'`,"4.1 io tte nIN
Installer/Builder ti-4 ! f 1=e tef efF7 a N,
Mailing Address 0 4 ,-}r _ , 4- AL `l.
Phone&Email d /412 v.."® R ic—pnt, 2 Q Cow
Engineer - 00`
Mailing Address _
Phone&Email r ' '
Contact Person for Building&Code Compliance: & ‘ �. Hide Phone: I lr 7f.X7 re,!
RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms X gallons per =total daily flow
per day bedroom Garbage Grinder Yes No
1980 or older 150 Installed? (circle one)
1981-1991 130 Spa or Hot. Tub Yes No
Installed? (circle one)
1992-Present 110 PO t)i
PARCEL INFORMATION: _
_Topography ` Flat-Rolling Steep Slope %Slope
Soil Nature IPSand Loam Clay Other
Groundwater At what depth? Y .o rn I tawk.
Bedrock/Impervious material _At what depth? or./A.,
Domestic Water Supply Municipal _Well(if well,water supply from any septic system absorption is—ft.)
Percolation Test Rate: 1 per minute per inch(test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION: 1.- Gk)3 k.)k tJ
_
Tank size airli gallons(min.size 1,000 gallons,add 250 gallons_for-each garbage cylinder or spa/hot tuba--¢:==-� --sue,..
System Absorption field with#2 stone Total lengthy"_lb E ft.;_ -Each Trench 7-t-eis_ft. a-rAii gate.
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 a i-r-equirernents-ni.tbe�Town Queensbury Sanitary Sewage
p '- ; LI! V E
Disposal Ordinance. . �y 4 N �p
PRINT NAME: _14_,„_iyi
lit v P R ,T
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SIGNATURE: 3 C a ,4 3 Sr t;s ��; lm E:__ A 1
Town of Queensbury Building&Code Enforcement COMMUH °r• LVEL P yi�sed.March 2018