application SEPTIC DISPOSAL PERMIT APPLICATION Office Use Only
- 742 Bay Road,Queensbury,NY 12804
'town ofescensburti Permit#: .30 0 2-`0 J -
P:518-761-8256 www. ueensbury.net
Tax Map ID#: 308.18-1-43 Permit Fee:$ +5 ; Invoice#: 161.81)
Project Location: 17 REVERE ROAD Septic Variance? Yes ✓ No
Primary Owner(s) JOHN OBST
of
Mailing Address 17 REVERE ROAD,QUEENBSURY NY rE La
Phone & Email " � 111
Installer/Builder SANITARY SEWER SERVICES mg( t 1 20 M
Mailing Address LUZERNE ROAD,QUEENSBURY NY
Phone & Email 5187963760 ' "TOWN • 's
a &CODES
Engineer TOM CENTER
Mailing Address 73 SHERIDAN STREET,GLENS FALLS,NY 12801
Phone & Email TCENTER36@YAHOO.COM
Contact Person for Building&Code Compliance: GEORGE DRELLOS Phone: 5187963760
RESIDENCE INFORMATION:
Year Built #of bedrooms X gallons per bedroom =total daily flow Garbage Grinder Yes No
1980 or older Installed? (circle one)
1981-1991 Spa or Hot Tub Yes No
Installed? (circle one)
1992-Present 4 110 440
PARCEL INFORMATION:
Topography _ ✓-Flat Rolling Steep Slope %Slope
Soil Nature Sand Loam Clay Other
Groundwater At what depth? DEEPER THAN 6'
Bedrock/Impervious material At what depth? NONE
Domestic Water Supply ✓ Municipal _Well (if well,water supply from any septic system absorption is ft.)
Percolation Test Rate: 1'-5' per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size 1000 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: 20 X 30 FT BED
Holding Tank System Total required capacity? ;tank size ;#of tanks
NOTES: 1.Alarm system&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.
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.
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PRINT NAME: Yf e � .�� DATE: S ®/ 77/2
441,10,
SIGNATURE: t%
Town of Queensbury Building&Code Enforcement Revised February 2017