application SEPTIC DISPOSAL PERMIT APPLICATION Office Use Only
742 Bay Road,Queensbury,NY 12804 al)-- ,�
Town ofCZccnsbury Permit#: 0 P �7!0tc)
P:518-761-8256 www.queensburv.net
Tax Map ID#: 301.14-1-71 Permit Fee:$ 1-5 ; Invoice#: I`J.+'lo
Project Location: 1 Judmar Lane Septic Variance? Yes ' No
Primary Owner(s) AMY BLANCHARD
Mailing Address 1 JUDMAR LANE,QUEENBSURY NY
Phone & Email f ; rt, ---
1
Installer/Builder SANITARY SEWER SERVICES II ,
- I ----- -._- 11 i 1 4
Mailing Address LUZERNE ROAD,QUEENSBURYNY !P I MAY 2 8 2019 (L)ji I
Phone & Email 5187963760 1 a _ 8 1
Engineer TOM CENTER L
TO OF QUEl_IVb8UY BUILDING& conPRI
Mailing Address 73 SHERIDAN STREET,GLENS FALLS,NY 12801 6n��'
Phone & Email TCENTER36@YAHOO.COM
Contact Person for Building&Code Compliance: GEORGE DRELLOS Phone: 5187963760
RESIDENCE INFORMATION:
Year Built #of bedrooms X gallons per bedroom =total daily flow Garbage Grinder Yes No
1980 or older Installed? (circle one)
1981-1991 Spa or Hot Tub Yes No
Installed? (circle one)
1992-Present 3 110 330
PARCEL INFORMATION:
Topography ✓ Flat Rolling Steep Slope %Slope
Soil Nature Sand Loam Clay Other
Groundwater At what depth? DEEPER THAN 6'
Bedrock/Impervious material At what depth? NONE
Domestic Water Supply j Municipal _Well (if well, water supply from any septic system absorption is_ft.)
Percolation Test Rate: 1'-5' per minute per inch (test to be completed by licensed engineer/architect)
PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size 1000 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 ft.; Each Trench ft.
Seepage Pit with#3 stone How many: ;Size:
Alternative System Bed or other type: 20 X 25 FT BED
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 agr a to abide by these and all requirements of the Town of Queensbury Sanitary Sewage
Disposal Ordinance.
PRINT NAME: DATE:
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Town of Queensbury Building&Code Enforcement Revised February 2017