application Office Use Only
/04111141 SEPTIC DISPOSAL PERMIT APPLICATION Permit#: ' ou�Ie• k j
Permit Fee: $ ; Invoice#: 125kt,
T n.rn f .hurr
Septic Variance? Yes ✓ No
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742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net
Tax Map ID#: : 7-- - - 1\.0
Project Location: /1.t4 j w�y p /(Mr1
• A• •licant: �_
Name(s): OA tr w �.. ._.� I11�[-3i#1l ii\f/,I�F r1
/ / �- 111.
Mailing Address, C S Z: � _ � y,.,
Cell Pho e: ( 4, y' ) a-a- , 4 Land Line: _( ts.,..
Email: ��- r.— 0
TOWN OF OUEENSBURY
• Primary Owner(s): BUILDING&CODES
Mailing Address, C/S/Z: II /144,,, Oi.
Cell Phone: _Plc( op i.1 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): 6 (( /✓✓. . k i
Contractor Trade: Sc j r C .32'J
Mailing Address, C/S/Z: y ) /1J , ,/ Y /6)-FCY
Cell Phone: _( ) Land Line: _( $ i y ) 63/
Email:
• En ineer s : pp
Name(s): a✓/'j
Mailing Address, C/S/Z: /� `j /t'la,�,�...t, ,�.! -$ L y)—J f lr /V Y
Cell Phone: ( ) Land Line: _( ?f( ) 6?S"- 3 c-.c
Email:
Contact Person for Building & Code Compliance: /5--1 ) h/.3 k
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 40
1980 or older 150 3 l s-o 4-j Installed? (circle one)
1981-1991 130 Spa or Hot Tub Yes
Installed? (circle one)
1992-Present 110
PARCEL INFORMATION:
Topography Flat Rolling Steep Slope _%Slope
Soil Nature > nd Loam —Clay Other(explain:
Groundwater At what depth?
Bedrock/Impervious material At what depth?
Domestic Water Supply —Municipal —Well (if well,water supply from any septic system absorption is ft.)
Percolation Test Rate: per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size 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:
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: a1.`,0 T DATE: 3/LI/i
SIGNATURE: (\Q )A DATE: 3/11/11
Septic Application Revised February 2019