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deep hole perc test application©own otveesbury*Buing&Cotes Enforcement ce"742 Bay Road»Quscsbry,NY 1204 DEEP HOLE/PERC TEST SEP -Vo2Io-2019RequestforTownEngineerReview rropory owner:\AJLLLI AIM,FF.BOSV orone:AID-22|-TIAY Proven gores:FQ.BOX 4,LAKE GEORGE,NY 12845 Location of Test:5%ASSEMBLY POINT ROAD=tains:234,12—2-\lo “Applicant's Engineer: RUGS HALL: ARCHITECUZE enone:AIB-TA-0208|ean notcants agent: RUCINSKI HALL ALHITECIUE—Prone-SIB—TI-0208AdditionalNotes: 4,Reason for Request?[__]New Septic System x Replacement Septic System [_]Failed Septic System1subdivision(1 site Pian Review 2,Are Wetlands present?Yes [-]xo [[]unknown *Note:icant is required to et Je an engineer for design and testis the s\|.The Town Engineer's responsibility is to witness system testing only. PLOT PLAN:Piot plan,to scale,to be submitted with applicationFEESCHEDULE: a.$200 Flat Fee Date Pai AD]2015 Check No.1 b.OR Fee to be determined during To Be Determined: Site Plan /Subdivision review process SIGNATURE: In carrying out the provisions of Article IV,the Local Board of Health or the enforcement officer may engage the services of a qualified professional consultant for expert review and recommendation arising from the carrying out of the provisions of Art.IV,including but not limited to the review of plans, specifications and reports,attendance at inspections,dye tests,deep hole test pits,septic related deep hole and percolation tests,system installations,and any other aspect of any matter contained in this Art. IV,and any costs incurred in such review shall be paid to the Town by the owner of the property before ‘any approval can be granted under this Art.IV shall become effective within 30 days of presentment of an invoice for same,whicheveris sooner.Such costs shall not exceed $1,500 without prior written notice to the party to be charged with same. My signature below indicates |have thoroughly read and understand the instructions,agree to the submission requirements and have completed the application.|also fully understand that additional engineering fees may be necessary per Town of Queensbury Local Law 136-14D. SIGNATURE OF APPLICAN’Date: SIGNATURE OF AGENT:vate: [2 BX Zo/F Original (B &C File)Canary (Planning)Pink (Applicant)Gold (Town Clerk)