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Office Use Only
SEPTIC DISPOSAL PERMIT APPLICATION
Permit#: : :3 3 -�® /9
Permit Fee: $ ; Invoice#: /5711
Septic Variance? Yes No
Town of C)ueensbury
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensburv.net a t
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Tax Map ID#: ,90C1t 15 - $ ®--14 v) MAY 2 8 2019 i '
Project Location: (0 S --i��' i L NJ aAvgL
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• Applicant:
Name(s):
Mailing Address, C/S/Z: - 7 1--4 �� �1 j I 3
Cell Phone: _(_ ) j/ ----C, C Land Line: _( L, �vP
Email: Tra a- 0 5 a % Dec s £-QC
• Primary Owner(s): _
Name(s): (j am .Jk1 [ ) ' rU 1L
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Mailing Address, C/S/Z: LLk eg_ca � �° N 7$�'�
Cell Phone: _( ) ." Y 4 - 45 Land Line: _( )
Email: P i 61/4,1
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Check if work will be performed by homeowner' A.
• C ntractor: Workers' Comp documentatio , must be submitted with this application
Contact Name(s): 476,A,AL K 'A;l�.A,A _
1�Contractor Trade: V-�(.AV i I qr) , 2.,,r. o 1 'e
Mailing Address, C/S/Z: S•0 I A u- aoati\J-1-14 10 ' 1 127
Cell Phone: _( 3 IC) ) iligei - 0 ) *�9 Land Line: ( il/A—' )
Email: J/fr
• Engineer(s): �---
Name(s): fO if-1 I _
Mailing Address, C/S/Z: 1 E�1 b P-, A i-e ' `r�1-L5 1- ) � 3q
Cell Phone: _( 6 d ) 7 1i Land Line: _( )
Email:
Contact Person for Building & Code Compliance: tit- ; ti H 61)
Cell Phone: ( (t) 9i ® ea� 3 Land Line: _( 4t{
Email: l r- , , i
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RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms: X gallons per =total daily flow
per day bedroom Garbage Grinder Yes No 6
1980 or older 150 Installed? (circle one)
Spa or Hot Tub Yes �16
1981-1991 130 Installed? (circle one) 1�
1992-Present 110743 ,•,- ,e•----,
PARCEL INFORMATION:
Topography Flat Rolling Steep Slope %Slope
Soil Nature Sand Loam _Clay _Other(explain: )
Groundwater At what depth? Co I
Bedrock/Impervious material At what depth? ,fe11 ~-
Domestic Water Supply ><Municipal _Well (if well,water supply from any septic system absorption is ft.)
Percolation Test Rate: 69 raj per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size Ina) 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 11,120 ft.; Each Trench 11:5 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 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: 6 r' `l r"f`-A F►` ► __ DATE: 5/hp I 13
SIGNATURE: 4.7 DATE: ./ / /7
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Revised February 2019