application CommunityDevelopment Office
, �, � p
i,,,, Town of Queensbury • 742 Bay Road • Queensbury, New York •12804
Office Use Only #' l rvo zv._. t 1 9..3
TAX MAP NO. PERMIT NO. o-v-0 PERMIT FEE f OOO ' 20 lel
APPROVALS: ZONING TOWN CLERK
APPLICATION FOR SEPTIC DISPOSAL SYSTEM PERMIT: A PERMIT MUST BE OBTAINED
BEFORE WORK
IIy,S�APPLICATI�N IS SUBJECT TO REVIEW BEFORE ISSUANCE OF A VALID PERMIT.
OWNER: \v�V� `Arpl�Irr// SS )(1
C I3S_,, ( �
ADDRESS: 5 9 min—
Ai\( 0V11[�i041n J. ADDRESS: Lam.()(/V err �/(V O►('f e
PHONE NOS. c i�� 63 b 3 69 / PHONE NOS. Sly'-1 / O- g 1 9
LOCATION OF INSTALLATION: 5
9 Wojt f \-oc ik.a
RESIDENCE INFORMATION:
YEAR BUILT NO.OF X COMPUTATION = TOTAL DAILY FLOW
BEDROOMS (Gallons per bedroom) GARBAGE GRINDER
1980 or older k
X 150 = INSTALLED?
1981 -1991 X 130 \._
SPA OR HOT TUB
1992-present X 110 = INSTALLED?
PARCEL INFORMATION:
/ TOPOGRAPHY: FLAT ROLLING STEEP SLOPE •' t��-
/ SOIL NATURE: SAND LOAM t 15 C E U •V
- n
✓ GROUNDWATER: AT WHAT DEPTH? 2019 I!)
/ BEDROCK/IMPERVIOUS MATERIAL: AT WHAT DEPTH? A
✓ DOMESTIC WATER SUPLY: MUNICIPAL WELL (If well:w.ter STGWIttigfin. a..,Stgarp,on is: ft)
BUILDI G 1
✓ PERCOLATION TEST: RATE IS PER MIINUTE PER I• - o •e completed by a licensed professional
engineer or architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION: All ir:cividual sewage disposal systems must be designed by a licensed professional engineer or
architect(unless installed in a Planning Board approved subdivision).
TANK SIZE: GALLON (MIN. SIZE IS 1,000 GAL.)Add 250 gallons to the size of the septic tank for each garbage grinder,
spa or whirlpool tub. V cam)e +ox-. \ 0 r\14
SYSTEM TYPE: ,
❑ABSORPTION FIELD(WITH NO. 2 STONE) Total length ft. Each trench X
❑SEEPAGE PIT(S)(WITH NO. 3 STONE) How many? Size?
❑ALTERNATIVE SYSTEM Bed or other type?
❑ HOLDING TANK SYSTEM Total required capacity? Tank size? Number of tanks?
NOTE: ALARM SYSTEM AND ASSOCIATED ELECTRICAL WORK MUST BE INSPECTED BY A TOWN APPROVED ELECTRICAL
INSPECTION AGENCY. PLEASE REVIEW LIST PROVIDED.
For your protection, please note that pursuant to Section 136-29 of the Code of the Town of Queensbury, any-permit or approval
granted which is based upon or is granted in reliance upon any material misrepresentation or failure to make a material fact or
circumstance known by or on behalf of an applicant,shall be void.
I have read the r-• , io with respect to this application and agree to
abide by the • ., all r! )irements of the Towensbury QUESTIONS? CALL 761-8256 OR EMAIL
S. itary list..,. Ordinance. codesvnciueensburv.ne' 4r9-
VISITSig ,,,jir;!of er-.IfIFi•esponsible Date OUR WEBSITE FOR MORE INFORMATION
�/ www.queensburY.net