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application Office Use Only Permit#: -O SEPTIC DISPOSAL PERMIT APPLICATION Permit Fee: $ ; Invoice#: iS�o Septic Variance? Yes ✓ No Town of Queensbury 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.queensbury.net Tax Map ID#: Project Location: c 1 on c! Qrt e u'5"(Y '/ • Applicant: Name(s): F ftA( alnoJvtt S Mailing Address, C/S/Z: Q), fv< Po cf /MAI J1 057Pv� Cell Phone: _( 511 ) [.go - a/054 Land Line: ( Email: J5}-- e_ v'a.A-e@ c7,SAc t,c won • Primary Owner(s): Name(s): C ,� PCn� S Mailing Address, C/S/Z: J;;fk Qt GI 0,_ASL- JrL A Y /Z O`-I Cell Phone: _( 514, ) 2-(„0 'tit 4 Land Line: ( Email: ❑ Check if all work will be performed by homeowner only • Contractor: Workers' Comp documentation must be submitted with this application Contact Name(s): ) 0k A ( . DM45 Contractor Trade: .x. c a 'cz Mailing Address, C/S/Z: P Q ifo O5-7t '-) Cell Phone: _( ) ,v6 o 90S4 Land Line: _( Email: Ji\-exeav4,.e AA a.: • Engineer(s): i _ Name(s): ' '� Mailing Address C/S/Z: IJJ Cell Phone: _( ) Land Line: _( ) 1l �` ' ���'° 22 cl� . Email: i TOWN N OF OI a E; SE: P,V BUI Dili ' r",: i;''O�M j Contact Person for Building & Code Compliance: Cell Phone: ( ) Land Line: ( Email: [cntir Annliratinn Revised February 2019 RESIDENCE INFORMATION: Year Built Gallons #of bedrooms: X gallons per =total daily flow per day bedroom Garbage Grinder Yes Nq 1980 or older 150 - 1-A t © 00 Installed? (circle one) 1981-1991 130 Spa or Hot Tub Yes cN�y�� Installed? (circle one) `` 1992-Present 110C% PARCEL INFORMATION: Topography Flat Rolling Steep Slope %Slope Soil Nature X Sand Loam _Clay Other(explain: Groundwater A what depth? Bedrock/Impervious material A what depth? Domestic Water Supply Municipal _Well (if well,water supply from any septic system absorption is ft.) Percolation Test Rate: ,I, per minute per inch (test to be completed by licensed enginee /architect) 2't t) (2- VA?On- PROPOSED SYSTEM FOR NEW CONSTRUCTION: tJ �� \NL``Z Q-3(9 C)\) b Tank size c� 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 ilk ft.; Each Trench Zk?14sP � H8 1 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 and 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. 3. As-built drawings must be submitted prior to the inspection, if there has been a change to the submitted plans. 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. PRINT NAME: ® IN. 1M DATE: .C/Z1l1 �1 SIGNATURE: DATE: Jf4 L/f ccntir nnliratinn Revised February 2019