application Office Use Only
Permit#: 50 O - Z0 k.ci
SEPTIC DISPOSAL PERMIT APPLICATION permit Fee:$ 5- Invoice# 1153
Septic Variance? Yes ✓ No
Town ofCLecnshury
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensburv.net
Tax Map ID#: 50e) • 8 • 1- -2.-. ,
Project Location: 7 l
t9 , se-„_B,e, ,.vim 3 e 9
• Applicant:
Name(s): ,e,,le, ...1--).?5 - z f),., 'eel,-1 i-Cl
Mailing Address, C/S/Z: itee)E ,Q)-c, . cd Sas-c..4-e-r14w1 Aif' J2-, 66
Cell Phone: _( ,171f3 ) � -6/o-7 Land Line: _( 97 ) �,�� -1048
Email: (J et: .,,e -> 6 racl "c-i--r o e 5.. , 6esVP"1
• Primary Owner(s):
Name(s): /Jibc-ar)--- A) ,e,'-.
Mailing Address, C S Z:
Cell Phone:_(,57 3 ) ,F, —Si'i 3 Land Line: _( )
Email:
❑ Check if all work will be performed by homeowner only
• Contractor: Wor ers' Com9 documentation must be submitted with this application
Contact Name(s): c<eLr, Olt",
Contractor Trade: (j ee,/c ,", i .)) 4i,,;7c 1-i-C,
Mailing Address, C/S/Z: 1505- 41e . - O ; 4 'eA 1-oc;‘4..,, ski /0 l;
Cell Phone: _(9/13 ) .4 -- e 707 Land Line: _( :5/ ) ,cam f- /c /5
Email: fie&34 �n r', girt-id a),"4-Vt/e®5 . /a®
• Engineer(s):
5ECEOVIE ":
Name(s): r--
Mailing Address, C/S/Z: I(`� Alp )
.:_,,)
Cell Phone: Land Line: L - t
Email: I TOWN OF OUFFNSBURY
BUILDING&CODES
Contact Person for Building & Code Compliance: i e4,.". i �ii tij":J'e-L
Cell Phone: _(57/3 ) i.i..pc,-? Land Line: (*",>f5 ) 57v Jaye
Emai l:
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 Installed? (circle one)
1981-1991 130 Spa or Hot Tub Yes No
Installed? (circle one) />
1992-Present 110
PARCEL INFORMATION:
Topography )y( Flat Rolling Steep Slope %Slope
Soil Nature ` Sand 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 I.eoO 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: eeli,f
e DATE: ��1
SIGNATURE: �' DATE: i
Septic Application Revised February 2019