application SEPTIC DISPOSAL PERMIT / Office Use Only
DATE Received
Tax Map ID
TAX MAP ID Permit No. �
Permit Feey r7 L0
LOCATIONOFINSTALLATION 1V ' " Approvals:
APPLICANT -r l✓C ry PHONE/E-MAIL 260 -6l`'3Z_
p e
ADDRESS '/ 0-`
/NSTALLEW/9tIRDER: v �N� 4-4 e PHONNE/E-MA
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ADDRESS: Q- k Z �l P fi S � /(1
OPHauE/E-MAO.
Address c,
CONTACT PERSON FOR BUILDINe&CODES COMPLIANCE' O PNONE 6�w�
RESIDENCE INFORMATION
Year Built #of bedrooms X Gallons per bedroom =Total Daily Flow
1980 or older Garbage grinder installed 1 —Y N
1981-1991 Spa or Hot Tub installed
1992-Prasant
(PARCEL INFORMATION
Topography Flat rolling _Steep slope _%slope
Soil Nature Sand _Loam _Clay _Other
Groundwater At what depth? SPS De f a L s
Bedrock/Impervious Material At what depth?
Domestic Water Supply Municipal _Well(if well,water supply from any septic system absorption is
Percolation Test Rate: per minute per inch(test to be completed by licensed engineering/architect)
PROPOSED EYSTEM FORNI-W CONS_TRUCRON
Tank Size gallons(minimum size 1,000 gallons,add 250 gallons to size for each garbage grinder or spa or hot tub)
System Type Absorption Beld with#2 stone Total length ft.;Each trench x
Seepage Pit with#3 stone How many: :size
Alternative System Bed or other type? c�/
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&approved. The installed system must match the Septic system
layout on file-no exceptions.
QECLARAnoN: 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 know by or on behalf of an applicant, shall be void. I have read the regulations
and agree to abide by tl ese and all equir errts of the Town of Queensbury Sanitary Sewage Disposal Ordinance.
Print Name: Date:
Signature: Date: / t
Town of Queensbury Building&Codes Septic Disposal Permit July 2014