application i, Community Development Office
4E.` „j Town of Queensbury • 742 Bay Road • Queensbury, New York •12804
Office Use Only
TAX MAP NO. PERMIT NO.�-5 1 Y1 `� PERMIT FEE .t-00 1 Q - 1
APPROVALS: ZONING TOWN CLERK
APPLICATION FOR SEPTIC DISPOSAL SYSTEM PERMIT: A PERMIT MUST BE OBTAINED
BEFORE WORK BEGINS. APPLICATION IS SUBJECT TO REVIEW' ORRE�ISSUAtNCE OF A VALID PERMIT.
OWNER: (/1r(� ru INSTALLER._ 4—*1).d 54,„Li j 19-4— -
ADDRESS: 3 l" r 6k:A r 01, S ADDRESS: ')-- (A)w-12(V C r 45, • /lf'Yt•6\�
PHONE NOS. PHONE NOS. I- SC "9�' �\5`(
LOCATION OF INSTALLATION: i Or c i^ to r GA i,
RESIDENCE INFORMATION:
NO.OF COMPUTATION
YEAR BUILT X = TOTAL DAILY FLOW
BEDROOMS (Gallons per bedroom) GARBAGE GRINDER
1980 or older X 150 = INSTALLED?
1981 -1991 X 130 = SPA OR HOT TUB
1992-present 3 X 110 = 5 INSTALLED?
PARCEL INFORMATION: ' E 7 1E a ViEri
✓ TOPOGRAPHY: FLAT ROL G STEEP SLOPE %SLti•: JAN 1 1 pig
✓ SOIL NATURE: SAND LOAM CLA,: OT
✓ GROUNDWATER: AT WHAT DEPTH? TOWN OF QUEENSBURY
BUILDING&CODES
V BEDROCK/IMPERVIOUS MATERIAL: AT WHAT EPTH?
✓ DOMESTIC WATER SUPLY: MUNICIPAL WELL (If well:water supply from any septic system absorption is: ft)
✓ PERCOLATION TEST: RATE IS PER MIINUTE PER INCH[mpij (Test to be completed by a licensed professional
engineer or architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION: All ir,csvidual sewage disposal systems must be designed by a licensed professional engineer or
architect(unle5§;stiaAle,d 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.
SYSTEM T E: LL
ABSORPTION FIELD (WITH NO. 2 STONE) Total length)- 3 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 regulations with respect to this application and agree to
abide b and all requirements of the Town of Queensbury QUESTIONS? CALL 761-8256 OR EMAIL
Sani e Disposal Ordinance. _1/--/1 codestSciueensburv.net
i VISIT OUR WEBSITE FOR MORE INFORMATION
S of Person Responsible Date www.queensburV.net