application ---;,1464'
J SEPTIC DISPOSAL PERM11 APPLICGA►TIQ. f • - Use Onl
n ___ 742 Bay Road,Queensbury,N _ C E O VL P
roar,of t rrer s-bur-
P: 518-761-8256 www.quee s V.
P � #:
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Tax Map ID#: 5. G 2 - — I bl MAY 0 8 2019 715 t Fee:$7 ,00; Invoice#: 1SO 3
Project Location: U ke ; n of I N bF�����5- .Septi t Variance? Yes No
Primary Owner(s) f\1\
e($ A j_ry BUILDING&CODES
Mailing Address 4 Ci PNC r,c.j A Or ,
Phone & Email I,c(,-`� Z1
Installer/Builder d
Mailing Address J L Wei Vi Oyer S.f 0VoCkc�S\nv(
Phone & Email S 191_ \11 `
Engineer
Mailing Address
Phone & Email 1II LL
Contact Person for Building&Code Compliance: �r i �ek,l Phone: 5 LI)6)-D J
RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms X gallons per =total daily flow
per day bedroom Garbage Grinder Yes NZ/
1980 or older 150 Installed? (circle one) _
1981-1991 130 Spa or Hot Tub Yes N
Installed? (circle one)
1992-Present 110 ‘) l `i" ,��
PARCEL INFORMATION: 1
Topography L/f t Rolling Steep Slope %Slope
Soil Nature A Sand Loam Clay Other
Groundwater At lat depth?
Bedrock/Impervious material At hat 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 Q NEW CONSTRUCTION:
Tank size 1b `slons (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 &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 OrdinanceCo (
II
PRINT NAME: Of ¶ J9 L\ DATE:
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SIGNATURE: DATE: c J J �/
Town of Queensbury Building&Code Enforceme Revised March 2018