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SEPTIC DISPOSAL PERMIT A? wet
01
Sept! i r ce? v Yes No
Town of C`ueensbury
742 Bay Road,Queensbury,NY 12804 MAR 1 8 19
P:518-761-8256 www.queensbury.net
TOWN OF QUEENSBURY
BUILDING&CODES
Tax Map ID#: 227.17-2-23
Project Location: 19 Churchill Road
• Applicant:
Name(s): Molly Moynihan
Mailing Address, C/S/Z: 19 Churchill Road Queensbury, NY 12804
Cell Phone: ( 860 ) 463-9570 Land Line: _(
Email:
• Primary Owner(s):
Name(s): same as applicant
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: _(
Email:
❑ Check if all work will be performed by homeowner only
• Contractor: Workers' Comp documentation must be submitted with this application
Contact Name(s): J ?"4 - 'MC•-.(Mucr ,
Contractor Trade:
Mailing Address, C/S/Z:
Cell Phone: ( ) Land Line: _(
Email:
• Engineer(s):
Name(s): Hutchins Engineering
Mailing Address, C/S/Z: 169 Haviland Road Queensbury, NY 12804
Cell Phone: _( 518 )260-7499 Land Line: ( 518 ) 745-0307
Email: tutchins@hutchinsengineering.com
Contact Person for Building & Code Compliance: same as Engineer
Cell Phone: ( ) Land Line: (
Email:
Septic Application Revised February 2019
RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms: X gallons per =total daily flow
per day bedroom Garbage Grinder Yes No
1980 or older 150 2 (Design to 3) 110 330 Installed? (circle one)
Spa or Hot Tub Yes No
1981-1991 130
Installed? (circle one)
1992-Present 110
PARCEL INFORMATION:
Topography 1 Flat Rolling Steep Slope %Slope
Soil Nature Sand I Loam _Clay �Other(explain:
Groundwater At what depth? Mottling @ 36"
Bedrock/Impervious material At what depth? More than 58"
Domestic Water Supply _Municipal ✓Well(if well,water supply from any septic system absorption is 64.9 ft.)
Percolation Test Rate: 11-15 per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size 1.000 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: (2) ELJEN trenches @37'each=74 LF(see plans)
Holding Tank System Total required capacity? ;tank size ;#of tanks
NOTES: 1. Alarm system and 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. 3. As-built drawings must be
submitted prior to the inspection, if there has been a change to the submitted plans.
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 all requirements of the Town of Queensbury
Sanitary Sewage Disposal Ordinance.
PRINT NAME: ° 4Ft (4 Gt-Ni DATE: C e (,
SIGNATURE: DATE:
Septic Application Revised February 2019