septic applicationSEPTIC DISPOSAL PERMIT APPLICATION|office use OnlyTomeSLBTELS256muaduendbunynetremtr:SEP-O620-20%)
Tax Map ID #:Permit Fee:$TO_;invoice #2242
Project Location:A SS Pen b ly Pose A.Septic Variance?Yes No
Primary Owner(s)|VV";[fa ad Kath:bey ces)Lol ¢Deo NYS GsMailingAddress“PQ
Phone &Email IE
Installer/Builder 1MailingAddressFED Loppor Warren St Olu ens buns NYPhone&Email ®LK-7 96-C 194 anEngineerEthanHel
Malins/Aildress S4 Dix hve Glensfolls TL¥O1
Phone &Email ATX-14-o GY
Contact Person for Building &Code Compliance:C1 Phone:5({-36)-).¥/
RESIDENCE INFORMATION:
Year Built|Gallons|#of bedrooms |Xgallons per_|=total daily flow
per day bedroom Garbage Grinder Yes [no1980orolder}150 Installed?(circle one)
aoe Tog fia0l Spa or Hot Tub Yes wInstalled?(circle one)1992-Present|110 y 16 Guo =
PARCEL INFORMATION:L
‘Topography Zpfat Rolling Steep Slope %SlopeSoilNatureSandLoamClayOtherGroundwater‘At what depth?
Bedrock/Impervious material|At what depth?7p \AJZ.\-8,
Domestic Water Supply Municipal®“OWvert (if well,water supply from any septic system absorption is aE)Percolation Test Rate:er minute per inch (test to be completed by licensed engineer/architect)PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size [[J’5t\gallons (min.size 1,000 gallons,add 250 gallons for each garbage cylinder or spa/hot tubSystem|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:JX J WierHoldingTankSystemTotalrequiredcapacity?UU Woftanks
NOTES:1.Alarm system &associated electrical work must be inspected by a Town ed electrical inspection
agency;2.We will no longer allow systems to be covered until such time as an as-butlt plan if received Ae ‘approved.
The installed system must match the septic layout on file—no exceptions.}
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Declara ‘ny permit or approval granted which is based upon or is granted in rene upon any material:>representation or failure to make a material fact or circumstance known by or on behalf of an applicant,shall be void.1
have read the regulations and agree to abide by these and all requirements of the Town of Queensbury Sanitary SewageDisposalOrdina
PRINT NAME:Th fap)to phy Be Ue .
DATE:N-5{9
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SIGNATURE:DsGELJo DATE:N51
Tov of usenstuy Bula Coaatcemeyh //esd Mare 2018