application .41111-4
u"'1 SEPTIC DISPOSAL PERMIT APPLICATION Office Use Only
-_ 742 Bay Road,Queensbury,NY 12804 p
Town°F�'"`en5i��r, P: 518-761-8256 www.queensbury.net Permit#: 3E"\`C 335" Acli
Tax Map ID#: r f 6 ( eer.
Permit Fee: $ —3 ; Invoice#: 1 `�-
Project Location: I b 0..-- C� J�wy`� Or Septic Variance? Yes `/ No
Primary Owner(s) vti-?49(-\ V i(,fr)r t `) &rc1!" O;iv\-e (),Vv ctier t\ ) .
Mailing Address
Phone & Email &G J5 �`�4—)`�h
Installer/Builder " S 5-epl-l`L
Mailing Address 4*� ,,V,e,V. 1�i �;��
� � , tA-c-e'iv)\,) L;.. M
Phone & Email tr—7/' U 1
Engineer I i
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Mailing Address 1 MAY 23 2019
Phone & Email !
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1, tr-NTOWN OF QI��I�SBU I .
_3 6j 2--`f
Contact Person for Building&Code Compliance: e, SUP : ' 94 5
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RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms X gallons per =total daily flow
per day bedroom Garbage Grinder Yes No
1980 or older 150 / Installed? (circle one)
/
1981-1991 130 Spa or Hot Tub Yes No
Installed? (circle one)
1992-Present 110
_PARCEL INFORMATION: /
Topography / FI Rolling Steep Slope %Slope
Soil Nature Sand Loam Clay Other
Groundwater At w/lilat depth?
Bedrock/Impervious material At Ohat depth?
Domestic Water Supply Municipal _Well (if well, water supply from any septic system absorption is ft.)
Percolation Test date: per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION: (°�;. I ocy '_)t'Inr?,r- L tA r
_Tank size gallons(min. size 1,000 gallons,adcr250 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 thirements of the Town of Queensbury Sanitary Sewage
Disposal Ordinan el
�' i-00f ( J4Z DATE: 31 -PNTNAME. -
SIGNATURE: DATE: J Z3.-1 i
Town of Queensbury Building&Code E ce t Revised March 2018