application ,4--':------------,„
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4 SIVTIC:DISPOSAL PERMIT Pk;.PPLiCAritokl office Use Only
742 Car Read:Catieerisburv,r\IY
final,,f t 2iteensIlliry p:t,-18_761_g256- ,- ::,..:1-;.:1 Permit#:
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Tax Map in M 2 ff- -1-- 6-5- Permit Fee:$ 1J ; invoice#: IL(S-to
Project Location: /0?3 2 ives-i- 41 f--. k_ ,t2. Septic Variance? Yes No
Primary OwnerN I------/nni
Mailing Address IV Z Ar,..1---/1/ ii- iie oe
Phone &Email
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InstaiieriBuiider I-)47va141,- 1-6-L-e,/z ,.&7- ,./e-c-- , \\1'i 1 1 HAI 0 2 2n l' 1
Mailing Address Po 6,y Zi y 6 Ie. ivr 1---)4,/,([ A:9-----/2 `')/L
Phone &Email ca - 'rn -- S 7ó0
Engineer
Mailing Address :.
Phone & Email
Contact Person for ButiclIng&Code Compliance: 6eo Aar Phone:Sid'-796,_57‘a
RESIDENCE INFORMATION:
Year Built- I #of bedrooms I X gallons per bedroom I =total daily flow Garbage Grinder Yes , /No
1980 or older I installed? (circle one) Y
1981-1991 I 02, 1 /17C2 2_2 0 Spa or Hot Tub Yes z
installed? (circle one)
1992-Present I I
PARCEL ONFOREViATOIN:
Topography I W.- Flat Rolling Steep Slope %Slope
Soil Nature / Sand Loam Clay Other
Groundwater At what depth? r--A
Bedrock/Impervious material At what depth?
Domestic Water Supply I ) Municipal Well(if well,water supply from any septic system absorption is ft.)
Percolation Test I Rate:/--5- per minute per inch (test to be completed by Incensed engineer/architect)
PROPtSED SYSTEM FOR NEW CINSTIRUCTMIt
Tank size IMF; gallons(min.size 1,000 gallons,add 250 gallons for each garbage cylinder or spa/hot tub
System 1 Absorption field with#2 stone I Total length A179 ft.; Each Trench .35 ft.
Seepage Pit with#3 stone I How many: ;Size:
• Jvit- Alternative System Bed or other type:
_ /1// Holding Tank System Total required capacity? ;tank size ;#of tanks
NOTES: 1.Alarm system g.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.
Decllaration: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: DATE:
SIGNATURE: _... -ar - " e. DATE: S - 2 —/ 9
Town of Queensbury Building&Code Enforcement Revised February 2017