application .r
Office Use Only
, Permit#: q 37 7— i g
Y} �� SEPTIC DISPOSAL PERMIT APPLICATION Permit Fee:$ ";'4;= ; Invoice#: d
�_ Septic Variance? Yes No
Town of Cjueensbury
742 Bay Road,Queensbury,NY 12804
P:518-761-8256 www.queensbury.net
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Tax Map ID#: 2- D - - --- - -- _
Project Location: (C e—tt,igs ot, 5Li jLtii-
• Applicant: -1 ok , , Or ..UE E NSBURY
Name(s): \_. f\l'k-E---S VI -Lt--,e..../2-- CO it's° e ; DEVELOPMENT
Mailing Address, C/S/Z: ( ' .0.-it/it,,,, —_n , Ltic, Icor e-
Cell Phone: _( 'ilk ) 124 0 �-C ( Land Line: _( )
Email: CO cvV 1,°e:.16-vis- 4 eit4o, 0...„
• Primary Owner(s):
Name(s): /J .c14
Mailing Address, C/S/Z:
Cell Phone: _( ) Land Line: _( )
Email:
❑ Check if all work will be performed by homeowner only
• Contractor: W,,orkers' omp documentation must be submitted with this application
Contact Name(s): ,r' �
Contractor Trade: t _Ck-v it- ✓ if( J1i c,
Mailing Address, C/S/Z: () 2- 1'.'f 15: V
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Cell Phone: _(S1 r ) 3k, ( ]‘ ( Land Line: ( )
Email:
• Engineer(s):
Name(s): e_vie,�c .-`---
Mailing Address, C/S/Z:
Cell Phone: _( — " Land Line: _( )
Email:
Contact Person for Building & Code Compliance: N k"r "
Cell Phone: _( ' ) ? O C ` Land Line: ( )
Email: tS ,de
Septic Annlication Revised February 2019
RESIDENCE INFORMATION:
Year Built Gallons #of bedrooms: X gallons per =total daily flow
per day bedroom Garbage Grinder Yes Q19,1
1980 or older 150 0 D Installed? (circle one)
1981-1991 130 Spa or Hot Tub Yes No
Installed? (circle one)
1992-Present 110
PARCEL INFORMATION:
Topography Vliat Rolling Steep Slope %Slope
Soil Nature _ and Loam _Clay _Other(explain: )
Groundwater At what depth?
Bedrock/Impervious material At what depth?
Domestic Water Supply _Municipal _Well (if well,water supply from any septic system absorption is ft.)
Percolation Test Rate: per minute per inch (test to be completed by licensed engineer/architect)
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PROPOSED SYSTEM FOR NEW CONSTRUCTION:
Tank size /MO 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:
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.
TE: / 6PRINT NAME: %) �`� V-r-L-LjirDATE:d�
SIGNATURE: ____
''- ' DATE: 6 Mr i
Septic Application Revised February 2019